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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004877
Report Date: 03/29/2022
Date Signed: 03/29/2022 09:57:59 AM


Document Has Been Signed on 03/29/2022 09:57 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:WONG, TRICIAFACILITY NUMBER:
414004877
ADMINISTRATOR:WONG, TRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 722-0128
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:14CENSUS: 0DATE:
03/29/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Tricia Wong TIME COMPLETED:
10:10 AM
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On 3/29/2022 at 8:45A.M., Licensing Program Analyst (LPA), Luis J. Gomez met with licensee, Tricia Wong. Purpose of the inspection was explained and was an announced follow-up, prelicensing inspection to review corrections made. Present during inspection was the licensee and no children. Day-care Areas: Kitchen, Living room (Playroom), Bedroom #1, Bathroom #1 and the Outdoor Play Area. Off-limit Area: Studio unit, Garage and Driveway. LPA inspected facility with licensee for health and safety hazards.

At 8:50A.M., LPA observed the following: Required forms had been properly posted in entry way. Posted forms included: LIC610A, PUB 394 and LIC9148. In facility kitchen, LPA observed child size tables and chairs for snack and meals. In Bedroom #1, LPA observed infant cribs available for napping services. LPA reminded licensee to ensure cribs are equipped with properly sized mattresses and tight-fitting adjustable sheets. One cribs must be available for each infant child in care.

At 9:10A.M,. LPA inspected outdoor play area. Licensee’s outdoor playthings inspected were in good repair. Area was free of hazards or dangerous conditions.

Fire Clearance approval was received by the department on 3/11/2022.

During inspection, licensee submitted updated LIC279, LIC999 and LIC508 for Adult Occupant.

On 3/29/2022, Licensee will recommended approval for change of location/ large capacity licensure.

Copy of the report was reviewed and provided to the provider. This report will be kept in the facility file and made available for public review upon request.

SUPERVISOR'S NAME: Cindy InterianoTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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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