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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004022
Report Date: 09/15/2021
Date Signed: 09/15/2021 01:24:42 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:LI,XIAO YANFACILITY NUMBER:
384004022
ADMINISTRATOR:LI,XIAO YANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 272-9286
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 11DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Xiao Yan LiTIME COMPLETED:
01:45 PM
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Licensing Program Analyst, LPA Yee conducted an annual random inspection today. The purpose of the inspection was explained. Present at the daycare are the licensee, Xiao Yan, her husband, and 11 daycare children. Current residents are licensee, Xiao Yan, her husband, and their two daughters ages 25, 13. LPA and Xiao Yan toured the daycare areas and observed the following. Daycare area (lower level): One large room, bathroom, and backyard. The remaining areas are off-limit.
The home is equipped with a working smoke alarm, a carbon monoxide detector, and a fully charged fire extinguisher. The facility has age-appropriate toys and equipment, appear to be safe and clean. Licensee and husband have current CPR & 1st aid certificates which expire 12/7/2021. Child abuse mandated reporter training, AB1207 is current until 2/2023. All harmful objects, sharp objects, and toxic are stored out of reach of children and are made inaccessible from children in care. The facility provides snacks and meals. The last emergency was conducted on 8/16/2021. LPA observed no pools, spas, or other bodies of water on the premises. A Child Care Provider's Guide to Safe Sleep was discussed. LIC9227 "Individual Infant Sleeping Plan" was discussed and provided. The provider shall supervise infants while sleeping, document and maintained in the infant's file. The documentation shall include the date, infant's name, time of each 15-minute check. The children's roster was reviewed. The facility personnel summary report was reviewed with Xiao Yan, and it's current.

website: ccld.ca.gov. Title 22, Div 12, Chp3
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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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