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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380506504
Report Date: 01/17/2023
Date Signed: 01/17/2023 04:27:30 PM

Document Has Been Signed on 01/17/2023 04:27 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:SHEN, RUN MANFACILITY NUMBER:
380506504
ADMINISTRATOR:SHEN, RUN MANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 296-8722
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94108
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
01/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sulan Wu & Eric ChenTIME COMPLETED:
03:00 PM
NARRATIVE
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On January 17, 2023 at approximately 12:30pm, Licensing Program Analyst (LPA) Winnie Ly conducted an Unannounced Required - 1 Year Visit to this family child care home and met with Assistant Sulan Wu and Licensee's son Eric Chen. Purpose of visit was explained. Licensee was not present during the visit due to having an appointment. Present during the visit were 2 Assistants caring for 9 children. Licensee's son Eric Chen is present during the visit to help Assistants with showing LPA paperwork.

Day Care Areas are on the ground level with 1 bedroom, Living room, Kitchen and 1 Bath. Off Limit Areas are the kitchen and Licensee's bedroom. Assistant CPR expires 02/28/2023. Completed Child Abuse Mandated Reporter Training Certificate is on file.

LPA observed the home is clean orderly and properly ventilated. LPA also observed a 2A10BC Fire extinguisher, operable smoke detectors and carbon monoxide. There are no Fireplace or bodies of water in the home. Electrical outlets have child protective covers in place making them inaccessible to children. Chemical, detergents, cleaning compounds, medications, and other items of this nature are made inaccessible to children. Kitchen/Bathroom cabinets/drawers have child protective locks in place making all sharp objects or toxic house hold items inaccessible to children. First aid supplies are available for children. Facility conducts fire drills/earthquake drills on 11/08/2022 and was properly logged. Home has age appropriate toys and equipment available for the children in care.

During today's visit, LPA reviewed children's files and found 2 children's files did not have Immunization record on file. Missing Immunization record poses a potential health and safety risk to children in care. Type B is being cited today in accordance with the California Code of Regulations, Title 22, see LIC 809D.

LPA also found all children's files did not have the California Immunization Record (PM 286). Missing California Immunization Record (PM 286) poses a potential health and safety risk to children in care. Type B is being cited today in accordance with the California Code of Regulations, Title 22, see LIC 809D.

During today's visit LPA also reviewed Assistants' personnel files and found Assistants' Immunization Records were not available to be reviewed. Assistants missing Immunization Record poses a potential health and safety risk to children in care. Type B is being cited today in accordance with the California Code of Regulations, Title 22, see LIC 809D.

CONTINUED>>>
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2023
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: SHEN, RUN MAN
FACILITY NUMBER: 380506504
VISIT DATE: 01/17/2023
NARRATIVE
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This family child care home does not provide Incidental medical Services to children in care. 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 also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

LPA discussed Child Abuse Mandated Reporter Training AB1207 with Licensee. As of January 1, 2018 all staff will be required to complete Child Abuse Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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.

An exit interview was conducted and Plans of Corrections (POC) were developed and reviewed with Licensee. A copy of this report and appeal rights were discussed and left with Licensee whose signature on this form confirm receipt of reports. Notice of Site Visit was provided to licensee. Licensee was advised Notice of Site Visit to remain posted for 30 days. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023
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Document Has Been Signed on 01/17/2023 04:27 PM - It Cannot Be Edited


Created By: Winnie Ly On 01/17/2023 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SHEN, RUN MAN
FACILITY NUMBER: 380506504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 Assistants, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Licensee will collect Immunization Record from Assistants and email proof of record to LPA by 01/31/2023.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 9 children, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Licensee will collect Immunization Record from Parents and email proof of record to LPA by 01/31/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Garfield Leung
LICENSING EVALUATOR NAME:Winnie Ly
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/17/2023 04:27 PM - It Cannot Be Edited


Created By: Winnie Ly On 01/17/2023 at 02:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SHEN, RUN MAN
FACILITY NUMBER: 380506504

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 9 out of 9 children, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2023
Plan of Correction
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Licensee will obtain PM 286 and transfer children's immunization record over. Licensee will email proof of children havein PM 286 to LPA by 01/31/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Garfield Leung
LICENSING EVALUATOR NAME:Winnie Ly
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2023


LIC809 (FAS) - (06/04)
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