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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004483
Report Date: 10/22/2021
Date Signed: 10/22/2021 04:14:15 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:LI, SUSANNA YANNAFACILITY NUMBER:
384004483
ADMINISTRATOR:LI, SUSANNA YANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 218-0633
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 0DATE:
10/22/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Susanna Yanna LiTIME COMPLETED:
11:30 AM
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Licensing Program Analyst, LPA Yee conducted a pre-licensing inspection today. LPA met with the applicant, Susanna Yanna Li. LPA inspected the entire house with Susanna. Susanna is the only person that lives at the facility. Days and hours of operation: Monday to Friday between 8:00 AM to 6:00 PM.

Day Care Areas: living room, dining room, and bathroom. The off-limit area: kitchen, garage, the entire upper level (3 bedrooms), and backyard. The backyard is not inspected today. If used, it needs to be inspected by the licensing department. The applicant owns this home. Documentation is on file. The home has a carbon monoxide detector, smoke detector, and fully charged fire extinguisher. The applicant has one year of experience. Fire clearance approval is on file. LPA advised the applicant to conduct emergency drills once every six months and keep a log sheet.

The applicant has required immunization records on file. CPR and 1st aid are current. 8 hr of H&S is current and on file.

This facility plans to provide Incidental Medical Services - IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 102417. A Plan for Provides 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. A written IMS plan will be submitted by next week.

LPA review AB 1207 with the Licensee. As of January 1, 2018, all staff members are required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. AB 1207 certificate is on file. The applicant has been advised that all adults living or working at the facility must have fingerprint clearance before having contact with children.

LPA discussed the safe sleep regulation concepts, Individual Infant Sleeping Plan (LIC9227) form was provided. A packet of records to be maintained and posting requirements were explained and provided. Individual Infant Sleeping Plan, LIC9227 was provided. Website for forms and regulations: www.ccld.ca.gov.

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: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2021
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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