414004884-4-14-2022-05-CC-CQUO-CDGRUB-20220414131938

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004884
Report Date: 04/14/2022
Date Signed: 04/14/2022 01:20:43 PM

Document Has Been Signed on 04/14/2022 01:20 PM - 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:	EMPIRE INFANT		FACILITY NUMBER:	414004884
ADMINISTRATOR:	TONG, LINDA		FACILITY TYPE:	830
ADDRESS:	3080 LA SELVA STREET		TELEPHONE:	(650) 678-3638
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	20	CENSUS: 4	DATE:	04/14/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Linda Tong & Sarah Jen		TIME COMPLETED:	01:30 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 April 14, 2022 at 9:00am, Licensing Program Analyst (LPA) Catrina Quimbo met with applicant, Linda Tong, and center director, Sarah Jen, for a pre-licensing inspection. This is a change of ownership application (facility previously licensed #414002600). Facility is currently operating under change of ownership process. Applicant and director understand applicant's liability responsibility during change of ownership process. The applicant is requesting for a combination center of a preschool license and an infant license. Under the preschool license, the applicant is requesting for 120 children (2 years to entry into first grade). Under the infant license, the applicant is requesting for 20 children (3 months to 24 months). Fire clearance was obtained 04/06/2022. The facility will operate Monday through Friday from 8:00am to 6:00pm. Children are signed in and out of facility with authorized parents' written signatures. Facility operates as a Chinese immersion program. LPA inspected facility for health and safety hazards as well as measuring the space to calculate capacity. Indoors: Program operates on ground floor of building. There is 1 classroom that is used for the infant program. Infant classroom was calculated for 744.86 sq. ft allowing for a capacity of 21 children. The bathroom accessible to infants is located in preschool classroom #3. Applicant and director are aware infants and preschool age children are not to use shared bathroom at the same time. Shared bathroom includes 5 toilets and 5 sinks. Total allowable capacity for toilets and sinks are 25 children. All sinks accessible to children do not provide water that is warmer than 120 degrees. Infant classroom has diaper changing table within arms reach of an adult sink. Garbage cans have tight fitting lids. (Continue Report on Page 2...)

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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: EMPIRE INFANT	FACILITY NUMBER: 414004884
	VISIT DATE: 04/14/2022

NARRATIVE

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The classroom used for the infant program was observed to be clean and equipped with a fully charged fire extinguisher and carbon monoxide detector. Facility maintains a fire alarm system. All furnishing, toys and equipment was observed to be safe, age appropriate and in good condition. Sufficient storage space for children's personal belongings is located inside the classroom. Cribs and cots are to be utilized for napping infants. Facility does not provide sheets or blankets. Cribs and cots are sanitized weekly or as needed.

The facility is adequately ventilated and free of insects and bugs. First Aid Kits and emergency supplies are located inside the classroom, inaccessible to children. Cleaning products are stored in classroom's high cabinets, child proof locked cabinets or off limit areas, inaccessible to children.

Facility also contains a food prep area located in infant classroom. Food prep area is to be made off limits to children. LPA reminded applicant and director cleaning products and other chemicals are not to be stored with food. Program provides morning snacks, lunch and afternoon snacks. LPA reminded applicant and director children who bring their own items are to be labeled with each child's individual names. Children bring their own individually, labeled water containers that is refilled at the facility. Water is available to children both indoors and outdoors.

Medications with children’s individual names and required documentation will be stored in classroom’s high cabinets in off limit area. Medications that require refrigeration will be stored in food prep area's refrigerator. This facility plans to provide Incidental Medical Services –IMS. For IMS information, see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. A Plan of Operation
that includes 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.

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SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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: EMPIRE INFANT	FACILITY NUMBER: 414004884
	VISIT DATE: 04/14/2022

NARRATIVE

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Outdoor: The outdoor area includes 2 separate playgrounds. Infant playground was measured for 1,890.74 sq. ft allowing for a capacity of 25 children. Entire outdoor area is enclosed with an least 4ft high fence. Outdoor area was observed to be clean. Adequate shade is provided by trees and building in surrounding area. Playground is equipped with age appropriate play structure that has resilient padding cushioned underneath.

LPA reminded applicant and center director to conduct and document emergency disaster drills at least once every six months. Applicant was reminded infant and preschool children cannot co-mingle at any time.

Applicant and center director were reminded that all adults 18 and over responsible for administration or direct supervision of staff, persons who provides care and supervision to children, and staff who have contact with children, 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 Child Care Center. 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 applicant and center director 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 applicant and director 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.

LPA reviewed with center director the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

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SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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: EMPIRE INFANT	FACILITY NUMBER: 414004884
	VISIT DATE: 04/14/2022

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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Prior to recommended licensure for requested capacity of 20 children, following must be completed:
-LPA's second review of change of ownership application.
-Transfer all staff members cleared fingerprints from Fac #414002600 to Fac# 414004884.

Exit interview conducted and report was reviewed with applicant, Linda Tong, and center director, Sarah Jen.

SUPERVISOR'S NAME: Cindy Interiano	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Catrina Quimbo	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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