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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002996
Report Date: 10/11/2019
Date Signed: 10/11/2019 10:04:48 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:LIN, XUE YAN AND YU, PEI PINGFACILITY NUMBER:
384002996
ADMINISTRATOR:LIN, XUE YAN AND YU, PEI PFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 670-0996
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:14CENSUS: 10DATE:
10/11/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Xue Yan Lin & Pei Ping YuTIME COMPLETED:
10:15 AM
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1, An annual random inspection was conducted today. Present at the facility are licensee, Xue Yan, co-licensee, Pei Ping, helper and 12 children. This is a large FCCH. The fire clearance is on file. The home is equipped with a carbon monoxide detector, fully charged fire extinguisher and a smoke detector. The purpose of the inspection was explained. No change in the daycare areas. Daycare areas (lower level): family room, study room, bathroom, and backyard. The remaining areas of the house are off-limits. Current residents at the facility are licensee, Xue Yan, her husband, her husband, her mom, and their children ages 5 years old, 3 years old. The home is ventilated properly. Both licensee and co-licensee have current CPR, 1st aid until 3/3/2021. Required immunization for staffs are on file. All staff members have been completed “Child Abuse Mandated Reporter Training, AB1207”. LPA reminded licensee that all staff members need to renew the training once every two years. A written IMS is on file. The facility provides snacks and lunches. The last emergency drill was conducted on 9-13-2019. The facility carries childcare insurance. The capacity for large FFCH was discussed. A copy of the capacity worksheet was provided during the inspection. The discipline policy is communication. SIDS “A Child Care Provider’s Guide to Safe Sleep” information was discussed and provided today. The children roster was reviewed. The facility is in compliance.

www.ccld.ca.gov. Title 22, Div 12, Chp 3
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2019
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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