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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004214
Report Date: 01/07/2020
Date Signed: 01/07/2020 10:00:42 AM

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:WU, XUE XIAFACILITY NUMBER:
384004214
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
01/07/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Xue Xia WuTIME COMPLETED:
10:15 AM
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Licensing Program Analyst, LPA Yee conducted a pre-licensing inspection for an increase in capacity and location change today. I met with the applicant, Xue Xia Wu. This is a change of location previously licensed at 494 Campbell Avenue, San Francisco, CA. 94134 facility 384002707. LPA and Xue Xia toured the home. The street level consists of 2 bedrooms, 1 bathroom, living room, kitchen, dining room, storage room. The lower level consists of 3 bedrooms, 1 bathroom, storage room, kitchen, and backyard. Current residents are Xue Xia, her husband, 2 children (9mth old son, 4 yr old daughter). The home is leased. The lease agreement is on file. Daycare area (lower level only): Classroom #1, #2, #3, bathroom and backyard. Off Limit area: The entire upper level. No garage. The home is equipped with a working smoke alarm, a carbon monoxide detector, and a fully charged fire extinguisher. The home has age-appropriate toys and equipment available for the children in care. She states discipline she plans to use is redirection and some quiet time. Xue Xia has been advised all adults, 18 yrs and older living in the home, or helper must have fingerprint clearance prior to having any contact with children in care. Xue Xia has been advised, the home shall have proper heating and ventilation for children in care. Xue Xia states there are no Fire Arms/ Weapons in the home. All harmful objects, sharp objects and toxic are stored out of reach of children and are made inaccessible from children in care. Required immunization is on file. Child Abuse Mandated Reporter Training, AB1207 certificate is on file. 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, 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, Available at http://www.ada.gov/childqanda.htm SIDS information was provided. Fire clearance approval for large FCCH is on file.
Advisory: Steps leading to the bathroom is high, LPA recommends licensee to provide proper supervision when children are using the bathroom. Some concrete steps located in the backyard need cushioning. The licensee said she will place a cushioning ASAP.
LPA will recommend a large FCCH effective today.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2020
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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