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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004061
Report Date: 01/03/2023
Date Signed: 01/03/2023 12:10:02 PM


Document Has Been Signed on 01/03/2023 12:10 PM - 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:XU, YINGFACILITY NUMBER:
384004061
ADMINISTRATOR:XU,YINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 867-0647
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 11DATE:
01/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ying XuTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Yee conducted an Unannounced Required - 1 Year inspection today. The purpose of the inspection was explained. Present at the facility are the Licensee, Ying Xu, 2 helpers and 11 children. The facility personnel summary report was reviewed with Ying Xu and she said it's correct. Current residents are licensee, Ying, her husband, their 13 years old daughter and 1 tenant. The facility operation hours are Monday - Friday, 8:30 am - 5:00 pm.

Daycare areas are (lower level): living room, dining room, bedroom, playroom, bathroom and back yard. The remaining areas of the home are off-limits.

The home is clean orderly and properly ventilated. The home is equipped with a fully charged fire extinguisher size 2A10BC, a smoke detectors, and a carbon monoxide. Smoke detector and carbon monoxide are in working condition. There are no bodies of water in the premises such as swimming pool or hot tub. All harmful objects such as sharp, chemicals, detergents, cleaning compounds, medication are made inaccessible to children in care. First aid supplies are available for children. The facility conducts fire drills/earthquake drills and was properly logged (10/25/2022). The disciplinary policy was discussed with Licensee today. The home has age-appropriate toys and equipment available for the children in care.

LPA reviewed the children's roster and staff records during the visit. Staff records are in order.

continue to the next page.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2023
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: XU, YING
FACILITY NUMBER: 384004061
VISIT DATE: 01/03/2023
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Licensee’s CPR and 1st aid certificate is current and will expire on 09-11-2023.

LPA discussed Child Abuse Mandated Reporter Training AB1207 with Licensee. As of January 1, 2018, all staff will be required to complete Child Abuse Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. The licensee completed AB1207 on 12/26/2022.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an updated Plan of Operation that includes 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: http://www.ada.gov/childqanda.htm

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 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.

Notice of Site Visit posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2023
LIC809 (FAS) - (06/04)
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