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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004725
Report Date: 06/03/2022
Date Signed: 06/03/2022 09:59:46 AM


Document Has Been Signed on 06/03/2022 09:59 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, JIEFACILITY NUMBER:
414004725
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
06/03/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jie XuTIME COMPLETED:
10:15 AM
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On June 3, 2022 at approximately 9:00am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, case management inspection. LPA met with licensee, Jie Xu, and explained the purpose of the inspection. Present in the home at start of the visit included licensee, licensee's spouse (W1), and 1 enrolled child (preschool age). All adults living and/or working in the home have a criminal record clearance on file.

Licensee requested to increase capacity to a large license May 4, 2022. Licensee obtained a fire clearance June 1, 2022. With licensee, LPA inspected the home for health and safety hazards. Hours of operation are Monday to Friday from 8:00am to 6:00pm.

Licensee rents the home which is single level, family home. The home consists of four bedrooms, two bathrooms, living room, dining area, kitchen, backyard, front yard and garage. The DAY CARE AREAS are bedroom #1 (napping room only), bathroom #1, living room, dining area and backyard area. The OFF-LIMIT AREAS are kitchen (pass by only), bedroom #2, bedroom #3, bedroom #4, bathroom #2, backyard's side alleys, and garage. All off limit areas are properly barricaded with child safety gates and/or locked doors.

At approximately 9:15am, additional enrolled child (preschool age) arrived to home. LPA observed home to be in good repair with proper temperature and ventilation. Home is equipped with a variety of age appropriate toys that were in good condition. Living room is cushioned with child safety padding that was observed to be clean and in good repair. All cleaning supplies, poisons, other chemicals and sharp objects were stored inaccessible to children on high shelves and/or off limit areas. Home contains a fireplace that is properly barricaded, separate from children in care.

Outdoor area is equipped with age appropriate toys and materials that were also in good working condition. LPA did not observe any pools, spas or bodies of water on the property.

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SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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 2


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: 06/03/2022
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At approximately 9:30am, 2 additional children (preschool age and infant) arrived to home.
Home is equipped with a fully charged fire extinguisher, multiple smoke/carbon monoxide detectors, and a working telephone on site. Per licensee, there are no weapons or pets in the home. Garbage cans have tight fitting lids. Licensee was reminded baby walkers, bouncers, jumpers and any other similar items are not to be used for children in care.

Licensee provides food service with breakfast, lunch and afternoon snacks. Food storage, sanitization, and children’s allergies were discussed. Licensee provides cribs, cots and mats for napping children in care. Safe sleep regulations and sanitization was discussed.

At approximately 9:40am, 1 additional child (infant) arrived to home. Present during inspection included 6 children (2 infants and 4 preschool age).

Licensee's CPR and First Aid training is current and will expire February 2023. Licensee's Mandated Reporter training is current and will expire October 2023. Licensee was reminded CPR , First Aid and Mandated Reporter training must be renewed every two years.

Capacity limits and ratios for a Large Family Day Care have been reviewed with licensee. LPA reminded licensee that a qualified assistant/helper must be present. Licensee was reminded when working without a qualified assistant/helper, licensee must operate as a small license.

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: http://www.ada.gov/childqanda.htm

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.

A large license will be effective on this date, June 3, 2022.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Jie Xu.
SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina QuimboTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2022
LIC809 (FAS) - (06/04)
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