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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004241
Report Date: 06/17/2020
Date Signed: 06/18/2020 11:41:36 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:GUO,MAYFACILITY NUMBER:
384004241
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
06/17/2020
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:May GuoTIME COMPLETED:
04:30 PM
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Licensing Program Analyst, LPA Yee conducted a Tele inspection today. This is an increase in a capacity inspection. Fire clearance for large FCCH has been approved and documentation is on file. Licensee owns this home. The control of the property is on file. The upper level consists of 2 bedrooms, 1 bathroom, living room, kitchen, dining room. The lower level consists of one large room, 1 bathroom, garage, and backyard. Current residents are May Guo, her husband, their 14 years old son. Daycare area (lower level only): one large room and backyard. The remaining areas of the home are off-limit. The home is equipped with a working smoke alarm, a carbon monoxide detector, and a fully charged fire extinguisher. All required immunization for staff is on file. A written IMS is on file. Licensee CPR and 1st aid are current. Child Abuse Mandated Reporter Training, AB1207 certificate is current. The facility will provide snacks and lunches. Capacity worksheet for a large FCCH was explained and provided. SIDS "A Child Care Provider's Guide to Safe Sleep" information was provided.

License for a large FCCH is approved effective today, 6/18/2020.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2020
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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