384002590-12-17-2019-05-CC-MROZ-BJXQ9A-20191217105801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384002590
Report Date: 12/17/2019
Date Signed: 12/17/2019 10:58:07 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:	CHEN, RAY		FACILITY NUMBER:	384002590
ADMINISTRATOR:	CHEN, RAY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 218-0632
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94132
CAPACITY:	14	CENSUS: 10	DATE:	12/17/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Jianlan Zhang		TIME COMPLETED:	11:20 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced Annual Random inspection. LPA met with staff and explained purpose of inspection. Present in home were a helper and 5 children (1 infant and 4 preschool age). A second helper and 5 more children (1 infant and 4 preschool age) arrived a short time later. Licensee is operating within capacity requirements on this day. LPA spoke to Licensee over the phone and discussed purpose of inspection. All adults living or working in the home have a criminal record clearance on file. Hours of operation are Monday to Friday 8:00am to 6:00pm. Day Care Areas (lower level only): Garage converted into a day care room (living room), family room, kitchen, and bathroom. Off Limit Areas: Entire upper level and backyard. LPA inspected day care areas of home with staff. LPA observed home to be clean and in good repair with proper temperature and ventilation. Per staff, there are no weapons, firearms, or bodies of water in the home. There is a variety of age appropriate toys and equipment in the home that are in good condition. Napping equipment is in good condition and properly stored. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There is a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone. Phone number listed is current. Four children records reviewed were complete. All children have a record of emergency identification information on file. Licensee's Pediatric First Aid/CPR certificate expires April 2020. Staff immunization is on file. Last emergency drill was conducted in November 2019. Emergency drills are conducted every month and are properly logged. (Continued on second page)

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHEN, RAY	FACILITY NUMBER: 384002590
	VISIT DATE: 12/17/2019

NARRATIVE

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(Continued from first page)

During inspection,

Staff was given information regarding Safe Sleep Practices, Technical Support Program (TSP), and Lead Poisoning Facts.
Staff was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
Staff was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com. If training is not available in native language, a statement can be written stating exemption until the translation is available and filed in staff record..
Staff was reminded about the Provider Information Notices (PINs) on CCLD website.
Staff was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00 am - 5:00 pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

No deficiencies cited today.

This report was reviewed and discussed with staff Jianlan Zhang. A copy of report was provided.
Notice of site visit was observed being posted and shall remain posted for 30 days.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019

LIC809 (FAS) - (06/04)

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