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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002986
Report Date: 03/30/2021
Date Signed: 03/30/2021 01:36:15 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:YE, PEIYIFACILITY NUMBER:
384002986
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
03/30/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:PeiYi YeTIME COMPLETED:
09:00 AM
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Licensing Program Analyst, LPA Yee conducted a virtual inspection today. This is an increase in capacity. Current residents are PeiYi, her husband, her mother-in-law, father-in-law, and their 6 years old son. No tenants living at the facility. All adults living or working in the facility have a criminal background check on file. Days and hours of operation: Monday to Friday between 7:00 AM to 10:00 PM.

Day Care Areas (upper level): Living room, dining room, kitchen, bathroom, and patio. The backyard is not licensed today. If PeiYi wishes to add the backyard, it needs to be inspected by the licensing department. Fire inspection is scheduled for 4/5/2021. The remaining areas of the house are off-limits. Off-limit areas are made inaccessible. The home has a carbon monoxide detector, smoke detector, and fire extinguisher.

Immunization records are on file. CPR and 1st aid are current. Lead Poisoning Prevention (LPP) certificate is on file.

Incidental Medical Services (IMS) policy was discussed. The licensee stated no children in her care need the services at this time.
LPA review AB 1207 with the Licensee. As of January 1, 2018, all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Licensee completed AB 1207 on 8/17/2019. A certificate is on file.

LPA discussed the safe sleep regulation concepts. A packet of records to be maintained and posting requirements were explained and provided. Website for forms and regulations: www.ccld.ca.gov.
COVID-19 Self-Assessment Guide and posting requirements were discussed.

Prior to licensure: Fire clearance approval is needed.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021
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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