214005715-1-8-2025-05-CC-JTSE-DCQPCA-20250108101137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 214005715
Report Date: 01/08/2025
Date Signed: 01/08/2025 10:11:54 AM

Document Has Been Signed on 01/08/2025 10:11 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	XA, WENDY		FACILITY NUMBER:	214005715
ADMINISTRATOR/ DIRECTOR:	XA, WENDY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 505-3158
CITY:	MILL VALLEY	STATE: CA	ZIP CODE:	94941
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	01/08/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:20 AM
MET WITH:	Applicant, Wendy Xa		TIME VISIT/ INSPECTION COMPLETED:	10:25 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 1/8/2025, at approximately 8:20AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an announced prelicensing visit at this home. LPA met with Applicant Wendy Xa (A1) and a staff member (A2). There were no children present during the visit. The residence is a one-story, three-bedroom home. Daycare Areas: Main Playroom, Main Classroom, Nap Room, Dramatic Playroom, Dining Room, Bathroom, Backyard and Front Yard. Off-Limit Areas: Bedroom #1, Garage, Laundry Room (located in Backyard), and Shed in the Front Yard. LPA, A1 and A2 inspected the home for any health or safety hazards. The home is equipped with functional carbon monoxide detectors. There are fully charged fire extinguishers present in the Main Classroom and the Kitchen that are at least size 2A10BC. There is a fireplace located in the Main Playroom that is secured to be inaccessible to children in care. Stairs are kept inaccessible to children with childproof gates. There are temperature and ventilation controls available for the comfort and safety of persons in the home. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children in care. Floor vents are barricaded to be inaccessible to children in care. There are age-appropriate toys and learning materials present in the home. There are cubbies available for children in care. Furniture is age-appropriate and free of rough or sharp edges. LPA observed cots to be present for napping use. Per Applicant, children will bring bedding from home and take it back once a week for cleaning. Children will bring lunch from home and the facility will provide snacks during the day. Continued on Page Two

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: XA, WENDY	FACILITY NUMBER: 214005715
	VISIT DATE: 01/08/2025

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
26
27
28
29
30
31
32

Page Two
LPA observed the Front Yard and the Backyard to both be enclosed by fences that are at least four feet high. Per Applicant, the Front Yard will be used for outdoor play. The Backyard will be used for outdoor activities such as gardening. Applicant stated that children will be taken out on neighborhood walks. There are no swimming pools or other similarly sized bodies of water present. There is a fountain present in the Backyard that is drained and free of water.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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) or (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.

LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Continued on Page Three

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: XA, WENDY	FACILITY NUMBER: 214005715
	VISIT DATE: 01/08/2025

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
26
27
28
29
30
31
32

Page Three
LPA discussed the safe sleep regulations with applicant 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 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.

On this date, 1/8/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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 platforms. 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.

Exit interview conducted and report was reviewed with the applicant, Wendy Xa.

Prior to approval of a large license, fire clearance must be received. Applicant may operate at a small Family Child Care Home capacity, pending fire clearance.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3