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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004214
Report Date: 12/22/2021
Date Signed: 12/22/2021 10:48:31 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:WU, XUE XIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 691-9966
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 5DATE:
12/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Xue Xia WuTIME COMPLETED:
11:00 AM
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Licensing Program Analyst, LPA Yee conducted a required one-year inspection today. The purpose of the inspection was explained. Present at the facility are licensee, Xue Xia, helper (sister), and 5 children. Current residents are Xue Xia, her husband, and their 2 children (2.5-year-old son, 6 yr old daughter). Daycare area (lower level only): Classroom #1, #2, #3, bathroom, and backyard. The backyard is not being used at this time due to the weather. Off Limit area: The entire upper level. The home is equipped with a smoke alarm, a carbon monoxide detector, and a fully charged fire extinguisher. Children's toys and equipment appear to be clean and in good condition. All harmful objects, sharp objects, and toxic are stored out of reach of children and are made inaccessible from children in care. Children files and staff files were reviewed. Child Abuse Mandated Reporter Training, AB1207 certificate for both licensee and helper were expired on 2/21/2021. The licensee said she will renew it and will submit it to CCL by the end of this month. Helper immunization is not on file. The licensee said she will locate the file and will submit it to CCL by the end of this month. The training must be renewed every two years. 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. The licensee said she has no children that need the service at this time. The safe sleep information was provided and a blank form of LIC9227 was provided. A roster was available. The licensee and helper have current CPR, 1st aid until 2/26/2022.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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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