384000808-12-15-2025-05-CC-BVAN-DPE32T-20251215165228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384000808
Report Date: 12/15/2025
Date Signed: 12/15/2025 04:52:49 PM

Document Has Been Signed on 12/15/2025 04:52 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	MOY, XIAO-SONG		FACILITY NUMBER:	384000808
ADMINISTRATOR/ DIRECTOR:	MOY, XIAO-SONG		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 664-3977
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 10	CENSUS: 5	DATE:	12/15/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:33 PM
MET WITH:	Xiao-Song Moy		TIME VISIT/ INSPECTION COMPLETED:	05:00 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 December 15, 2025, Licensing Program Analyst (LPA) Van conducted an annual inspection and met with the licensee, Xiao-Song Moy. The purpose of the inspection was explained, and the licensee granted LPA entry to the home. Upon entering, LPA observed the children were napping. At the time of inspection, the licensee and her assistant supervised five children (one infant and four preschool-age). The licensee adhered to her license capacity and limitations. All adults living and working in the home have criminal record clearance verified through the CDSS Guardian Background Check System, and have an eligible clearance status on file. The Childcare areas are on the ground floor only, consisting of a large playroom, a nap room, a kitchen, two bathrooms, and 1/2 of the backyard. The off-limit areas are the entire second floor, the garage, and the back half of the backyard, including the storage shed. All off-limit areas have been appropriately barricaded. Days and operations are from Monday through Friday, from 7:30 am to 5:30 pm. Along with the licensee, LPA inspected the home for potential health and safety hazards. The facility has appropriate temperature, lighting, and ventilation. The large playroom is partitioned into smaller areas using a children's bookshelf. Each section has a good selection of age-appropriate toys and equipment. All cleaning supplies, disinfectants, and other chemicals are stored on top shelves, out of reach of children. The facility is equipped with a fully charged 2A:10 BC fire extinguisher, multiple combination smoke and carbon monoxide detectors, and a working phone. Continued on page 2.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

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 5

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MOY, XIAO-SONG	FACILITY NUMBER: 384000808
	VISIT DATE: 12/15/2025

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 2.
The facility has a fully stocked first aid kit for children. There were no pools, spas, or bodies of water on the site.

According to the licensee, fire and earthquake drills were conducted once every other month. The most recent fire & earthquake drill was completed on September 26, 2025, and properly documented.

The outdoor area is fully enclosed with a fence and has a climbing and sliding structure in the middle. Soft rubber cushions have been installed beneath the equipment to ensure safety and prevent accidental falls.

A crib was observed in the nap room, which was free of blankets, toys, or pillows. The mattress fits its dimensions and has tightly fitted bed sheets. The fifteen infant sleep logs were provided to the LPA for review during the inspection. Upon review, it was found that the licensee properly documented the checks, including the 15-minute interval, child's name, dates, and staff initials.

LPA reviewed the children's records. The Licensee maintains complete records for all children in her care, including vaccination records and Parental Rights forms. LPA noted that each kid had a complete emergency information card that included the child's full name, phone number, and the name of the parent or authorized person who may be called in an emergency.

The Licensee and her assistant have current Pediatric First Aid/CPR certifications. They stay up to date with their immunizations and have completed the Mandated Reporter Training required by AB 1207.

All required licensing postings, including the facility license, parents' notification, and earthquake preparedness checklist, were posted correctly.

LPA discussed and informed the Licensee that she must be at home during childcare operation hours to ensure that the children in her care are always supervised. When the licensee must be absent from the house, the temporary absence should not exceed 20 percent of the hours the facility provides care per day.
Continued on page 3.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC809 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MOY, XIAO-SONG	FACILITY NUMBER: 384000808
	VISIT DATE: 12/15/2025

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 3.
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.

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: www.ada.gov/childqanda.htm

LPA discussed the safe sleep regulations with the Licensee and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the 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.

Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare 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 reviewed AB 1207 with the Licensee. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.
Continued on page 4.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: MOY, XIAO-SONG	FACILITY NUMBER: 384000808
	VISIT DATE: 12/15/2025

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 4.
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

During the exit interview, the LICENSEE, XIAO-SONG MOY, confirmed that there are no Registered Sex Offenders living in the facility, and LPA completed the RSO profile in FAS.

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

An exit interview was conducted, and the report was reviewed with the licensee, Xiao-Song Moy.

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Brendon Van
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC809 (FAS) - (06/04)

Page: 5 of 5