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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004537
Report Date: 03/24/2022
Date Signed: 03/24/2022 03:16:39 PM


Document Has Been Signed on 03/24/2022 03:16 PM - It Cannot Be Edited

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: 9DATE:
03/24/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Xiao Hong XieTIME COMPLETED:
03:30 PM
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Licensing Program Analyst, LPA Yee conducted a case management inspection today. Present at the daycare are licensee, Xia Hong, helper, and 9 daycare children (2 infants). Ms. Xie submitted a requested to add her backyard as part of the daycare. Today, LPA inspected the backyard and approved effective today.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2022
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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