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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002397
Report Date: 11/14/2019
Date Signed: 11/14/2019 09:52:29 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:GONG, YINGJUNFACILITY NUMBER:
384002397
ADMINISTRATOR:GONG, YINGJUNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 602-8921
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 12DATE:
11/14/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:YingJun Gong, ZhongXiong LiuTIME COMPLETED:
10:00 AM
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2, Licensing Program Analyst, LPA Yee conducted an annual random inspection today. There are 12 children, licensee, YingJun and one helper. Another helper arrived at 9 am. The purpose of the inspection was explained. LPA verified the facility personnel summary report with Ms. Gong, she said it's correct. Current residents are licensee, Ms. Gong, her husband, her mom, dad, and their 11 yr old son. Daycare areas are the same as previous inspection. Day-care areas, the lower level only: one large room, bathroom, and backyard. The remaining areas of the house are off-limits. The licensee has current CPR & 1st aid until 3/11/2020. Helper CPR & 1st aid is current until 9/15/20. Last emergency drills were conducted on 10-29-19. The home is equipped with a smoke detector, a carbon monoxide detector, and a fully charged fire extinguisher. The roster was reviewed during the inspection. Required immunization for staff is on file. This facility provides Incidental Medical Services - IMS. LPA reviewed storage of medication and equipment/supplies and reviewed children's, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 102417. 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, Available at http://www.ada.gov/childqanda.htm
Consent to administer medication form is on file. Ms. Gong said she will submit a written IMS plan by the end of this month. All staff members have been completed Child Abuse Mandated Reporter Training, AB1207. www.mandatedreporterca.com. A copy of the certificate is on file. LPA reminded licensee that the training needs to be renewed once every 2 years. SIDS "A Child Care Provider's Guide to Safe Sleep" information was provided. The capacity worksheet for large was explained and provided.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2019
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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