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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002632
Report Date: 03/11/2020
Date Signed: 03/11/2020 02:17:57 PM

COMPREHENSIVE INSPECTION
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:HUANG, YANFACILITY NUMBER:
414002632
ADMINISTRATOR:HUANG, YANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
6502882715
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:14CENSUS: 9DATE:
03/11/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:TIME COMPLETED:
02:30 PM
NARRATIVE
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On March 11, 2020 at 11:30 a.m., Licensing Program Analyst (LPA) April Cowan conducted an unannounced Annual Required Inspection and met with Licensee. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. Present in the facility is Licensee and three helpers caring for 9 children (4 infants and 5 preschool age). Licensee owns home, which is a 4 bedroom, 2 bathroom, two level house. Facility was inspected and Daycare areas are: Living room, bedrooms 1,2,and 3, bathroom 1, and back yard. Off Limit areas are: Bedroom 4 and kitchen.

LPA observed the following: Daycare area is clean, orderly, and equipped with age appropriate toys and equipment for the children. Home has sufficient lighting and ventilation. Home has a working telephone. At 12:00 PM, LPA observed that licensee's smoke and carbon monoxide detector did not work. Home has a fully charged fire extinguisher. Chimney in Living room is properly barricaded. There are no bodies of water in the Home. There are no poisons, detergents, or cleaning products accessible to daycare children. Licensee states there are no guns or weapons of any kind in the home. Licensee’s CPR expires in 3/20/2020. Licensee conducted last emergency drill on 2/12/20 and is properly logged. Discipline policy is mainly talking to children. See Next Page........
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: HUANG, YAN
FACILITY NUMBER: 414002632
VISIT DATE: 03/11/2020
NARRATIVE
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All required postings are properly posted. At 1:00 PM, LPA reviewed files. LPA observed that licensee did not have any immunizations on file for staff. LPA reviewed children's files. Children's files are complete with all required documents.
During inspection,
*Staff files were discussed.
*Incidental Medical Services (IMS) policy was discussed. Licensee states that she does not supply IMS at the time.
*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*Licensee was given information regarding ‘Safe Sleep’ practices.
An exit interview was conducted and plans of Correction were reviewed and developed with the Licensee. A copy of this report and appeal rights were discussed and left with licensee whose signature on this form confirms receipt of these documents.
> See attached page for deficiency cited today.
>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. Notice of site visit was observed being posted.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: HUANG, YAN
FACILITY NUMBER: 414002632
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2020
Section Cited

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1597.622
Employees or volunteers at family day care home; immunization requirements; records; exemptions
(a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement was not met as evidenced by:
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Based on record review, LPA observed that licensee did not collect immunizations for staff. This poses a potential risk to children in care.
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Type B
03/18/2020
Section Cited

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102417 (g)(1)
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to:

(1) Fireplaces and open-face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal. This requirement was not met as evidenced by:
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Based on observation, licensee did not make sure that smoke detector was charged and working. This poses a potential risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April CowanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2020
LIC809 (FAS) - (06/04)
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