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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001308
Report Date: 11/25/2019
Date Signed: 11/25/2019 10:37:44 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LAM, DONG GUIFACILITY NUMBER:
384001308
ADMINISTRATOR:LAM, DONG GUI S.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 290-8549
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:14CENSUS: 12DATE:
11/25/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Anna WangTIME COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Mok conducted an unannounced increased inspection today. LPA met with Anna Wang (helper) and another helper, All adults have fingerprint clearance. The purpose of the inspection was explained to them. Per Anna, the licensee is on vacation this week. She will be back on 12/2/2019. There were 12 children included 4 infants with 2 helpers present. Licensee owns this 4 story single family house. Licensee lives in the house with her son, her son's girlfriend, and her daughter who is minor. Day care area is the entire second level including, the living room, kitchen/dining area, the nap room and the bathroom room. The off-limit areas are the entire ground floor, third and fourth floor. LPA toured and inspected the facility for health and safety hazard. The house was clean and in order. Temperature and lighting were adequate. All toxins and harmful objects were either locked or made inaccessible. There were plenty of age appropriate toys, books, learning material, and children furniture available. All lower kitchen cabinets and drawers were latched. Window locks were installed to the windows in the living room to limit the windows to be opened up to 4 inches. There were a fully charged 2A10BC fire extinguisher, working smoke and carbon monoxide detectors, working telephone, and first aid supplies available in the house. Gate was installed at the stairway to prevent children access to the off-limit areas. All electrical outlets were covered. Soft cushioning was installed to part of the daycare area to prevent injury. Children's bathroom was clean and free of harmful items. Licensee provides breakfast, AM/PM snacks, lunch and dinner to the children. Cubbies were available for children to store their own belongings. Play pens and mats were used for napping. Per Anna, the fire drill has been conducted 2 times a year. The latest drill was conducted on 11/13/2019. Per Anna, there were no children on special medication. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care facilities and the ADA, available at: http://www.ada.gov/childqanda.htm. All required postings were posted. Children files were reviewed during the inspection. Licensee and helper completed the Child Abuse Mandated Reporter training. Licensee has current CPR/first Aid training, it will expire in 8/2020.

This report and notice of site visit were discussed with the licensee and must be made available to the public upon request. A Child Care Provider's Guide to Safe Sleep was provided to licensee during inspection. Notice of site visit was provided. For quarterly update on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy MokTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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