414004439-9-10-2019-05-CC-MROZ-BFVUXA-20190910155801

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004439
Report Date: 09/10/2019
Date Signed: 09/10/2019 03:58:08 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:	LI, JIN QIU		FACILITY NUMBER:	414004439
ADMINISTRATOR:	LI, JIN QIU		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 245-7979
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	14	CENSUS: 9	DATE:	09/10/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Jin Qiu Li		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Marie Rodriguez made an unannounced Annual Random inspection. LPA met with LIcensee Jin Qiu Li and explained purpose of inspection with the help of Google translate (English to Mandarin). Present at home was Licensee, Licensee's husband, and 9 children (toddler and preschool age). Licensee is operating within capacity and ratio requirements on this day. Licensee rents the single story home. Living in the home is the Licensee and the Licensee's husband and adult son. All adults living or working in the home have a criminal record clearance. Hours of operation are Monday to Friday from 8:00am to 6:00pm. Day Care Areas: Living room, kitchen, bedroom #2, bathroom #1, and backyard. Off Limit Areas: Bedroom #1, bedroom #3, bathroom #2, and garage. LPA inspected the day care areas of the home with Licensee. LPA observed the home to be clean and in good repair with proper temperature and ventilation. There are no bodies of water on the property. Per the Licensee, there are no firearms or weapons in the home. There is a variety of age appropriate toys and equipment in the home. The backyard has age appropriate toys and outdoor equipment which are in good condition. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There is a working smoke and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone. Three children's records reviewed were complete and included immunization records and parents' rights form. Licensee's record was reviewed and complete. Licensee's Pediatric First Aid/CPR certificate is current and expires September 2021. Licensee is unable to complete the Mandated Reporter training online due to English not being her first language. LPA advised for Licensee to write a statement of exemption until the proper translation was available in her primary language. Last emergency drill was conducted on September 3, 2019. Emergency drills are conducted every six months and are properly logged. (Continued on second page)

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) -26-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2019

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: LI, JIN QIU	FACILITY NUMBER: 414004439
	VISIT DATE: 09/10/2019

NARRATIVE

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(Continued from first page)

During inspection,

Licensee was given information on Safe Sleep Practices.
Licensee was reminded all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.662.
Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00am - 5:00pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov

No deficiencies cited today.

This report was reviewed and discussed with Licensee Jin Qiu Li. A copy of report was provided. Notice of site visit was observed being posted and shall remain posted for 30 days.

SUPERVISOR'S NAME: Alma Malig	TELEPHONE: (650) -26-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2019

LIC809 (FAS) - (06/04)

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