414004725-10-12-2022-05-CC-CQUO-CK5N94-20221012101516

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004725
Report Date: 10/12/2022
Date Signed: 10/12/2022 10:15:44 AM

Document Has Been Signed on 10/12/2022 10:15 AM - 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:	XU, JIE		FACILITY NUMBER:	414004725
ADMINISTRATOR:	XU, JIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 338-8177
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 8	CENSUS: 8	DATE:	10/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:15 AM
MET WITH:	Jie Xu		TIME COMPLETED:	10:30 AM

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 October 12, 2022 at approximately 8:15am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual inspection. LPA met with licensee, Jie Xu, and licensee's spouse, W1, and explained the purpose of the inspection. Present during LPA's visit included 8 enrolled children (4 infants and 4 preschool age). Licensee is operating within capacity limits and ratio during LPA's visit. All adults living and/or working in the home have fingerprint clearance on file. Hours of operation are Monday to Friday from 8:00am to 6:00pm. Licensee lives in the home with their spouse and minor child. The home is a single level, single family home that includes four bedrooms, two bathrooms, living room, dining area, kitchen, backyard and front yard. The DAY CARE AREAS are bedroom #1 (napping room only), bathroom #1, living room, dining area and backyard area. The OFF-LIMIT AREAS are bedroom #2, bedroom #3, bedroom #4, bathroom # 2 (located in master bedroom), and kitchen (pass through only), backyard's side alleys, and garage. Off limit areas are properly barricaded with child safety gates and/or child safety locked doors. With licensee, LPA inspected the day care areas for health and safety hazards. LPA observed home to be in good repair with proper temperature and ventilation. Licensee operates home as a Chinese Immersion program. There were a variety of age appropriate toys and equipment that were in good condition. LPA observed electrical outlets in day care areas to be made inaccessible with child safety covers and/or blocked by furniture. Home also includes a fireplace that is properly barricaded and made inaccessible to children. LPA observed cleaning supplies, poisons and other chemicals to be stored in home's high shelves and/or locked behind child safety locked cabinets or closets. Home is equipped with multiple, working smoke and carbon monoxide detectors, fully charged fire extinguisher, fully stocked first aide kit and a working phone on site. Phone number listed for licensee is current. Per licensee, there are no weapons or firearms in the home. (Continue Report on Page 2...)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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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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: XU, JIE	FACILITY NUMBER: 414004725
	VISIT DATE: 10/12/2022

NARRATIVE

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Entire backyard is fenced with an at least 5 ft. high fence. LPA did not observe any pools, spas or bodies of water on the property. Backyard is equipped with appropriate outdoor toys and equipment that are in good working condition. LPA observed backyards side alleys, that are off limit areas, to be made inaccessible with child safety gates.

LPA observed all required licensing documents to be properly posted in front door entrance, available for review. LPA reviewed eight children's records which were complete. Children's files have a record of emergency identification information on file. Infants that are under 12 months who are enrolled also have required infant individual sleeping habits form on file.

Licensee was reminded baby walkers, bouncers, jumpers or any other similar items are not allowed in a licensed family child care home.

Last emergency disaster drill was conducted 08/09/2022. Emergency drills are conducted at least once every six months and are properly logged and documented. Licensee also maintains safe sleep logs for napping infants in care. LPA observed sleeping logs for napping infants include the 15 minute time check of when infant was last checked on as well as the initials of the adult (licensee or W1) who last checked on them.

LPA reviewed licensee and W1's files which were also complete. Both licensee and W1 have proof of required immunizations on file. Both licensee and W1 have a current Mandated Reporter certificate that will expire 10/2023. Licensee's CPR is current and will expire 02/2023.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) / (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: www.ada.gov/childqanda.htm.
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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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: XU, JIE	FACILITY NUMBER: 414004725
	VISIT DATE: 10/12/2022

NARRATIVE

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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

No deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Jie Xu.

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

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