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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004022
Report Date: 09/20/2022
Date Signed: 09/20/2022 10:56:32 AM


Document Has Been Signed on 09/20/2022 10:56 AM - It Cannot Be Edited

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: 6DATE:
09/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Xiao Yan LiTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Yee conducted a Required - 1-year inspection today. The purpose of the inspection was explained. Present at the facility are licensee, Xiao Yan, her husband, and 5 daycare children. Another child arrived during the visit. Total census is 6. The facility personnel summary report was verified and current. Current residents are the licensee, her husband, and their children ages 26 years old, and 14 years old. Hours of operation are Monday to Friday from 8:00 am to 5:30 pm.

LPA and the licensee toured and inspected the daycare areas. DAY CARE AREAS: one large room, bathroom, and backyard. The remaining areas are off-limit. All off-limit areas are properly barricaded with child safety gates and/or locked doors.

LPA observed age-appropriate toys and furniture in good repair with proper temperature and ventilation. The facility does not have pools, spas, or bodies of water on the property. The backyard is enclosed with at least a 5ft high fence. The backyard is equipped with appropriate outdoor toys and equipment that are in good working condition. All cleaning supplies, poisons, and other chemicals were stored inaccessible to children behind child safety-locked cabinets.

The home is equipped with a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone on site. Per Licensee, there are no weapons or firearms in the home.

The children's roster is available. LPA reviewed children's files. The licensee and her husband have current CPR, and 1st aid certificates until 12/2023.

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SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2022
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: LI,XIAO YAN
FACILITY NUMBER: 384004022
VISIT DATE: 09/20/2022
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During Inspection:

- annual fees are current.

-LPA discussed the safe sleep regulations with the licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

-The licensee was reminded about Mandated Reporter training available on the CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com.
-The licensee was reminded about the Provider Information Notices (PINs) on the CCLD website.
Current AB1207 is on file until 4/4/2023.

The incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) / (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: www.ada.gov/childqanda.htm.

-The licensee was advised for any additional questions to contact the CCLD office, Monday to Friday, 8:00 am - 5:00 pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022
LIC809 (FAS) - (06/04)
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