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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004725
Report Date: 10/12/2020
Date Signed: 10/13/2020 01:00:51 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:XU, JIEFACILITY NUMBER:
414004725
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
10/12/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jie Xu (Jay)TIME COMPLETED:
12:30 PM
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"AMENDED"
Licensing Program Analysts (LPA) Mok conducted an announced Tele inspection with an applicant, Jie Xu (Jay) via ZOOM to complete the Prelicensing. There was an applicant's child (minor) present. The applicant applied for the Small Family Child Home license on 8/12/20. The applicant rents the one-story single-family house with four bedrooms, two baths, a living room, a dining room with adjacent kitchen, garage, and front & backyard. The applicant lives in the house with his wife and his son who is a minor. The daycare areas are the living room, dining room, hallway bathroom, bedroom #2(which is next to the main entrance), and backyard. The off-limit areas are the kitchen, bedrooms (#1- licensee's bedroom, #3- licensee's son), #4-Storage that is next to the garage), garage, front yard, and both side yards. LPA virtual inspected the unit for health and safety hazards. The front yard was completely fenced. The main gate at the front yard will be the main entrance of the daycare. The childproof knob was installed at the door to the garage in Bedroom#2 to prevent children access to the office limit area. There was a working cellular phone, and at least one working carbon monoxide and smoke detector, fully charged 2A10BC fire extinguisher, and first aid supplies available in the unit. The applicant also had hand sanitizer, disinfectant, and thermometer available by the Main doorway for screening when the children arrive to prevent COVID 19. LPA discussed with the applicant to ensure those items have to be made inaccessible to the children. The applicant also blocks the fireplace with a diaper changing table. The applicant covered all electrical outlets and sharp corners in the daycare areas. The applicant installed a gate at the stairway between the living room and dining room and at the kitchen entrance to prevent children from access. There were plenty of age-appropriate toys, books, learning material, a slide structure, and children's furniture available. Soft cushioning was installed on the entire floor to prevent injury in the living room. The children's bathroom was clean and free of harmful objects. The lower bathroom sink cabinet and drawers were free of the dangerous items. The backyard was completely fenced. Gates were installed to both side yards to prevent children access to the off-limit area. There were plenty of age-appropriate outdoor toys, ride-on toys, playhouse, children's furniture, and a slide structure with grass underneath as the soft cushioning available for the children. The applicant will provide breakfast, AM/PM snacks,& lunch to daycare children. The applicant has current CPR/First Aid training available; it will expire on 2/2021. LPA discussed with the applicant about the baby bouncers, baby walkers, exersaucer, Nap Nanny, Napping Portable, and other similar items are not allowed in daycare areas. LPA also discussed the new safe sleep regulations with the applicant. LPA provided a list of Records to be Maintain in the facility via e-mail to the applicant to use for all children in care, a chart of child care ratio, PIN 20-24-CCP (RECENTLY APPROVED SAFE SLEEP REGULATIONS IN EFFECT), and some information about COVID 19. This report will be kept in the facility file and shall be made available for public review upon request. Website for forms and regulations: www.ccld.ca.gov

LPA provided this report and other related documents to the licensee via e-mail. The licensee has to return a copy of the report with the signature to CCL via e-mail or mail.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cindy MokTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2020
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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