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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004182
Report Date: 09/17/2021
Date Signed: 09/17/2021 01:52:34 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:NG,CINDY YUE ZHENFACILITY NUMBER:
384004182
ADMINISTRATOR:NG, CINDY YUE ZHENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 452-9135
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY:14CENSUS: DATE:
09/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Cindy NgTIME COMPLETED:
02:15 PM
NARRATIVE
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On September 17, 2021 at approximately 12:30pm, Licensing Program Analyst (LPA) Winnie Ly conducted an Unannounced Required-1 Year Visit to this family child care home and met with Licensee Cindy Ng. Purpose of visit was explained. Present during visit were Licensee and daughter as assistant caring for 5 children.

Day Care Areas are on the ground level consists of large room, kitchenett and a bathroom. Off Limit Areas the entire upper level, garage and backyard. Licensee’s CPR expires 07/23/2023. Completed Child Abuse Mandated Reporter Training on File. Required Immunization Influenzas, Pertussis and Measles are on file.

LPA observed the home is clean orderly and properly ventilated. LPA also observed a 2A10BC Fire extinguisher, operable smoke detectors and carbon monoxide. There are no Fireplace or bodies of water in the home. Electrical outlets have child protective covers in place making them inaccessible to children. Chemical, detergents, cleaning compounds, medications, and other items of this nature are made inaccessible to children. Kitchen/Bathroom cabinets/drawers have child protective locks in place making all sharp objects or toxic house hold items inaccessible to children. First aid supplies are available for children. Facility conducts fire drills/earthquake drills on 09/01/2021 and was properly logged. Disciplinary policy was discussed with Licensee today. Home has age appropriate toys and equipment available for the children in care.

At 1:30pm-LPA reviewed 3 children's files. All files missing Licensing forms. Two children's records are not available for review. Having incomplete children's record poses a potential risk to children in care. Type B deficiency is being cited based on LPA Winnie Ly’s review of children's record in accordance with the California Code of Regulations, Title 22, see LIC 809D.

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SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie LyTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: NG,CINDY YUE ZHEN
FACILITY NUMBER: 384004182
VISIT DATE: 09/17/2021
NARRATIVE
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This family child care home does not provide Incidental medical Services to children in care. 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: http://www.ada.gov/childqanda.htm.

Licensee was also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

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.

LPA discussed the safe sleep regulations with 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.


An exit interview was conducted and Plans of Corrections (POC) were developed and reviewed with Licensee. A copy of this report and appeal rights were discussed and left with Licensee whose signature on this form confirm receipt of these reports.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie LyTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: NG,CINDY YUE ZHEN
FACILITY NUMBER: 384004182
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited

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Child's Records – children’s records are incomplete. This requirement is not met as evidence by:
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Based on LPA's review of children's record, 3 children's records are incomplete and 2 children's record are not available for review.. This is a potential health and safety hazard.
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A return visit will be conducted to verify correction by date 10/01/2021

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie LyTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021
LIC809 (FAS) - (06/04)
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