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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384001308
Report Date: 08/20/2025
Date Signed: 08/20/2025 04:58:24 PM

Document Has Been Signed on 08/20/2025 04:58 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LAM, DONG GUIFACILITY NUMBER:
384001308
ADMINISTRATOR/
DIRECTOR:		LAM, DONG GUI S.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 290-8549
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 7DATE:
08/20/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:50 PM
MET WITH:Dong Gui LamTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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On August 20, 2025, Licensing Program Analysts (LPAs) Leong and Badger conducted an unannounced case management visit. LPAs met with the Licensee, Dong Gui Lam, and explained the purpose of the visit.

At 2:44 PM, LPA Leong rang the doorbell, and S1 opened the door. LPAs introduced themselves, and S1 asked twice about the reason for their visit. LPAs explained that they were there for an unannounced visit from the Department of Social Services. LPA Bager presented her department-issued badge to S1. After the introduction, S1 walked into the home and closed the door, asking the LPAs to wait. However, S1 did not return. At 2:50 PM, someone inside the house buzzed the LPAs into the home. The facility will receive a deficiency for violating the department’s regulation regarding inspection authority

LPAs requested the children’s roster from the facility, and the licensee said she does not have one available. Therefore, the facility will receive a deficiency.

LPAs Leong and Badger informed Licensee, Dong Gui Lam that this report dated 8/20/2025 documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPAs Leong and Badger informed the licensee to provide a copy of this licensing report dated 8/20/2025 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Please refer to LIC 809D for today’s deficiencies.

Appeal Rights were given to the licensee.

A Notice of Site Visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Dong Gui Lam

NAME OF LICENSING PROGRAM MANAGER: Garfield Leung
NAME OF LICENSING PROGRAM ANALYST: Hanson Leong
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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 4
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)
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Document Has Been Signed on 08/20/2025 04:58 PM - It Cannot Be Edited


Created By: Hanson Leong On 08/20/2025 at 04:07 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: LAM, DONG GUI
FACILITY NUMBER: 384001308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
08/21/2025
Section Cited
CCR
102391(a)

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102391 Inspection Authority of the Department
(a) Any duly authorized officer, employee, or agent of the Department...

This requirement is not met as evidenced by:
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The licensee must review and familiarize with the Title 22 Inspection Authority regulations, under Child Care Regulations Section 102391 and develop a written plan to prevent future incidents
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Based on interviews and observations, the licensee did not comply with the section cited above. After the LPAs introduced themselves and showed their department-issued IDs, LPAs were not allowed into the home, which poses an immediate...
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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.
Garfield Leung
NAME OF LICENSING PROGRAM MANAGER:
Hanson Leong
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/20/2025 04:58 PM - It Cannot Be Edited


Created By: Hanson Leong On 08/20/2025 at 04:13 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: LAM, DONG GUI
FACILITY NUMBER: 384001308

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2025
Section Cited
CCR
102417(g)(8)

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102417 Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in...

This requirement is not met as evidenced by:
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LPAs printed form LIC 9040 (children's roster) and gave a copy to the licensee.

The licensee said she will fill it out and return it to LPA Leong via email.
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Based on interview, the licensee did not comply with the section cited above. The licensee stated she does not have a current children's roster available for review, which poses a potential health, safety or personal rights risk to children in care.
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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.
Garfield Leung
NAME OF LICENSING PROGRAM MANAGER:
Hanson Leong
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
Page: 4 of 4