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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002962
Report Date: 09/28/2021
Date Signed: 09/28/2021 05:38:04 PM

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:CHIBI CHAN TOOFACILITY NUMBER:
384002962
ADMINISTRATOR:YIP, JENNIFERFACILITY TYPE:
850
ADDRESS:800 PRESIDIO AVETELEPHONE:
(415) 202-7905
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:36CENSUS: 12DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Jennifer Yip, Shoshana KanzakiTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Andrea Medlin met with director for this required annual licensing visit. Purpose of visit explained. Facility operates their preschool program in the Booker Washington Community Center. There are 12 children present during the visit. Days and hours of operation: Monday-Friday 7:30AM-6:00PM. The facility has fully charged fire extinguisher that meet the minimum requirements, smoke detectors, and carbon monoxide (CO) detectors in facility. Children's bathrooms inspected; all toilets and hand washing facilities are in safe and sanitary operating condition. A separate staff bathroom is available and located upstairs in the community center. No pools, spas, hot tubs, fish ponds, or similar bodies of water are present. Per director, there are no pets and no firearms or weapons on site. Disinfectants, cleaning solutions, poisons and other items that are dangerous to children are inaccessible. Variety of age appropriate toys and materials for children is available. Classrooms are set up for child care and furniture and equipment for children is present. Facility provides a morning and afternoon snack; parents/guardians provide the meals for their child. Adequate first aid supplies are available. Children use cots for nap time; each cot is individually labeled and napping supplies are provided by the parents/guardians. Sick children will be separated from the group while waiting for parents to pick up. Outdoor play area inspected for health and safety hazards. The areas used for outdoors is completely fenced and activity space surfaces are free of hazards. The areas around and under high climbing equipment is cushioned with soft rubber padding. Facility maintains a scheduled outdoor rotation waiver for outdoor use. All the required licensing forms are posted in prominent accessible locations including: License, Parent's Rights (LIC 995), and Emergency Disaster Plan (LIC 610). LPA reviewed staff and children's files. In the children's files that were reviewed, each child has Emergency and Identification Information (LIC 700) (or comparable form with same information), Parent's Rights (LIC 995), and verification of immunization records. In the staff files reviewed, each has verification of meeting the educational requirements, mandated child abuse reporter training as compliant with AB1207, and verification of the required staff immunizations: measels (MMR) and pertussis (Tdap). Director has current Pediatric First Aid and CPR certification (exp 9/2023) on file.
This report is reviewed with director and a copy of this report must be made available for public review upon request. Notice of site visit posted and shall remain posted for 30 days
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
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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