414004494-9-14-2021-05-CC-ACON-C6V4FX-20210914190439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004494
Report Date: 09/14/2021
Date Signed: 09/14/2021 07:05:05 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:	ZHAO, YAN YU		FACILITY NUMBER:	414004494
ADMINISTRATOR:	ZHAO, YAN YU		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 828-3995
CITY:	PACIFICA	STATE: CA	ZIP CODE:	94044
CAPACITY:	14	CENSUS: 11	DATE:	09/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:57 PM
MET WITH:	Yan Zhao		TIME COMPLETED:	03:15 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	On September 14, 2021 at 1:57 PM, Licensing Program Analyst (LPA) Cowan conducted an Required - 1 Year inspection which included a toured the home and yard, and a review of the required day-care forms with the licensee today. Present in the home is Licensee, and helper, Jiehua Zhao caring for 11 children (3 infants and 8 preschoolers). Capacity and ratio requirements of children was observed in compliance today. This type of home is a single family home of 3 bedrooms and 1 bathroom. The day-care areas are the living/family room, one bedroom for napping, bathroom, and outside area. Off limit areas are: applicant's bedroom, children's bedroom, kitchen, and garage. Days and hours of operation: Monday - Friday 7:30 AM-6:00 PM. When LPA arrived, children were napping, and helper was supervising sleeping infants. LPA observed the following: Day-care 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, a working smoke and carbon monoxide detector, and a fully charged fire extinguisher. Licensee updated the facility phone number with LPA. 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 day-care children. Licensee states there are no guns or weapons of any kind in the home. Licensee’s CPR expires in 08/15/2022. Licensee conducted last emergency drill on 6/11/22 and is properly logged. Licensee provides daily snacks and meals. Discipline policy is mainly redirection. All required postings are properly posted. Licensee has required proof of immunization and Mandated Reporter Training certificate on file. Mandated Reporter expires 5/26/23 >>> See next page

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

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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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: ZHAO, YAN YU	FACILITY NUMBER: 414004494
	VISIT DATE: 09/14/2021

NARRATIVE

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At 2:31, LPA reviewed children's files. All files are complete with required licensing documents.

During inspection,
Precautions for the COVID-19 were discussed. Emergency Evacuations were discussed. LPA discussed safe sleep and PINs. Licensee is currently signed up to receive Licensing PINs

*Incidental Medical Services (IMS) policy was discussed.
*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.

>No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations.

>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 Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2021

LIC809 (FAS) - (06/04)

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