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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004061
Report Date: 01/15/2020
Date Signed: 01/15/2020 03:43:16 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:XU, YINGFACILITY NUMBER:
384004061
ADMINISTRATOR:XU,YINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 867-0647
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 9DATE:
01/15/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ying XuTIME COMPLETED:
04:00 PM
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3, Licensing Program Analyst, LPA Yee conducted an annual random inspection today. Upon arrival, the helper answered the door. Five minutes later licensee arrived. Current residents are licensee, Ying Xu, her husband, their 10 years old daughter, and 1 tenant. The facility personnel summary report was reviewed with Ying and she said it is correct. LPA inspected the daycare areas. Daycare areas (lower level): living room, dining room, bedroom, playroom, bathroom and back yard. The remaining areas of the home are off-limit. Fire clearance for large is on file. The home is equipped with a fully charged fire extinguisher, smoke detector, and a carbon monoxide detector. The home has age-appropriate toys and equipment available for the children in care. Licensee's CPR & 1st aid are current until 9/7/2021. Helper has current CPR, 1st aid certificate on file. Required immunization for licensee and helpers are on file. The facility provides snacks and lunches. A written IMS plan is on file. LPA discussed the Mandated Reporter Training, AB1207 that was effective on 1/1/2018. All staff must take the training and keep the certificate on file. The training needs to be renewed once every 2 years. Child Abuse Mandated Reporter Training, AB1207. www.mandatedreporterca.com. All staff members have an AB1207 certificate on file. Children's files were reviewed and in order. The last emergency drill was practiced in November-2019. SIDS " A Child Care Provider's Guide to Safe Sleep" was provided. Capacity worksheet was explained and provided.

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: 01/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2020
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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