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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004537
Report Date: 02/08/2022
Date Signed: 02/08/2022 11:31:39 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:XIE, XIAO HONGFACILITY NUMBER:
384004537
ADMINISTRATOR:XIE, XIAO HONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 706-8707
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 0DATE:
02/08/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Xiao Hong XieTIME COMPLETED:
12:00 PM
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Licensing Program Analyst, LPA Yee conducted a pre-licensing inspection today. LPA met with the licensee, Xiao Hong Xie. This is a change of location from 1009 Geneva Ave, SF, CA; license number 384003059. LPA inspected the entire home with Xiao Hong. Current residents are Xiao Hong, her husband, their children ages 14 years daughter, 8 years old son. Days and hours of operation: Monday to Friday between 7:00 AM to 7:00 PM.
Day Care Areas (lower level): living room, son's bedroom for napping only, and bathroom. The off-limit area: The entire upper level, laundry room, and garage. The backyard is not licensed today. If used, it needs to be inspected by licensing department. Licensee owns this home. The control of the property is on file. The home is equipped with a carbon monoxide detector, smoke detector, and fire extinguisher that meets the fire department standard are available. LPA advised the 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 until 8/21/2023.
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, an 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

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 for the applicant is on file and completed on 02/16/2020.

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

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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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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: XIE, XIAO HONG
FACILITY NUMBER: 384004537
VISIT DATE: 02/08/2022
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Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
LPA discussed the safe sleep regulations with applicant, 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 applicant 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.
LPA reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.
Individual Infant Sleeping Plan (LIC9227) form was provided. Technical support for COVID was discussed. Website for forms and regulations: www.ccld.ca.gov.


Fire clearance for large is on file. LPA will recommend a large license effective today, 02/08/2022.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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