384002205-1-23-2025-05-CC-JNAS-DD83JH-20250123171734

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384002205
Report Date: 01/23/2025
Date Signed: 01/23/2025 05:17:57 PM

Document Has Been Signed on 01/23/2025 05:17 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:	CHEN, XU MING		FACILITY NUMBER:	384002205
ADMINISTRATOR/ DIRECTOR:	CHEN, XU MING		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 566-8168
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 12	CENSUS: 10	DATE:	01/23/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:	Chutong Tang and Xiao Li Li		TIME VISIT/ INSPECTION COMPLETED:	05:40 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 January 23, 2025, Licensing Program Analysts (LPAs) Naves and Van conducted an annual unannounced visit to this family childcare home and met with 2 staff Xiao Li Li and Chutong Tang. Licensee was not present at time of arrival. Staff informed LPAs that licensee was at Costco and had left at noon. Purpose of visit was explained. Present during the visit were 10 children (4 infants and 6 school age) and the 2 helpers. The home was toured and inspected for health and safety hazards. Licensee owns the house. Licensee, her husband and their three children live at this home. Everyone living or working at this home day care has criminal record clearance. Licensee arrived at 2:30pm and stated she was at her other childcare center which she is the co-owner. According to the licensee, the center also had an unannounced annual visit currently being done. LPAs explained the importance of her being present at this facility and explained the temporary attendance requirement. Children were all napping upon LPAs arrival and 2 infants were observed by LPAs as swaddled while sleeping. The two infants were observed wrapped up in blanket while napping. At first look infant appeared to be in a sleep sack infant was in a loose oversized overall attire where legs could come out easily. One child had toys and a pillow in crib and a blanket used to cover the mattress was placed folded above mattress with edges folded up. LPAs explained the regulation for safe sleep. Day Care Areas: the living room, children's nap room, children's bathroom, the deck and entire backyard. Off Limit Areas: Licensee's bedroom, her children's bedrooms, the kitchen/dining area on the second floor, the entire ground level. Licensee’s CPR expires 02/11/2025 Required Immunizations: Influenzas, MMR TDAP and TB are on file. continued page 2 >>>>

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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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Document Has Been Signed on 01/23/2025 05:17 PM - It Cannot Be Edited

Created By: Jaclyn Naves On 01/23/2025 at 04:01 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: CHEN, XU MING	FACILITY NUMBER: 384002205
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

102425(f)

Infant Safe Sleep

An infant shall not be swaddled while in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above in 2 out of 4 infants being swaddled during nap.A blanket, pillow and books were inside crib with sleeping child. A blanket was used as a cover for mattress with edges folded upwardwhich poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/24/2025
	Plan of Correction
1 2 3 4	The Licensee must ensure compliance with the infant safe sleep regulations by removing loose items such as blankets, pillows, and toys from cribs or play yards during naptime. Infants must not be swaddled, and mattresses should be fitted with tight bedsheets. The Licensee will procure and replace these fitted bedsheets without using blankets as mattress covers. . Licensee will provide a written plan in place and educate staff on regulations for the safety of children in care.A follow-up visit is necessary to confirm that the issue has been appropriately addressed.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Ali Zebila

LICENSING EVALUATOR NAME:

Jaclyn Naves

LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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

FACILITY NAME: CHEN, XU MING	FACILITY NUMBER: 384002205
	VISIT DATE: 01/23/2025

NARRATIVE

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LPAs observed the home is clean orderly and properly ventilated. LPAs also observed a 2A10BC Fire extinguisher, operable smoke detectors and carbon monoxide. Per Licensee, there are no Firearms, 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 household items inaccessible to children. First aid supplies are available for children. Licensee conducts fire/earthquake drills and are properly logged last one done on 12/5/2024. If there was an ill child, staff would separate the child from the group while waiting for a parent to pick them up and isolate them in napping room. Home has age-appropriate toys and equipment available for the children in care.

LPAs reviewed children's and staff’s files today. All staff files are up to date; however, 2 children’s files were incomplete with incorrect name and gender of child and parent signatures missing on emergency medical treatment form LIC 627. All required posting documents are posted and visible.

The days and hours of the operation are Monday – Friday from 8:00 am – 5:30 am. The Licensee has valid childcare liability insurance through Acord.

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.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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

FACILITY NAME: CHEN, XU MING	FACILITY NUMBER: 384002205
	VISIT DATE: 01/23/2025

NARRATIVE

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LPAs discussed the safe sleep regulations with the Licensees 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.

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.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. 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 Licensees. 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. Effective July 1, 2020, Licensees must have proof of completion of EMSA certified lead poison training if applying for a change of location or capacity change to an existing license.

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.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

Page: 5 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHEN, XU MING	FACILITY NUMBER: 384002205
	VISIT DATE: 01/23/2025

NARRATIVE

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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, XU MING CHEN, confirmed that there are no Registered Sex Offenders living in the facility, and LPA completed the RSO profile in FAS.

See LIC 809D for deficiencies cited today.

LPA Naves informed licensee XU MING CHEN that this report dated January 23, 2025 document(s) (1) 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, LPA Naves informed the licensee to provide a copy of this licensing report dated January 23, 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.

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, Xu Ming Chen. Today’s report, notice of site visit, and appeal rights were printed and provided to the Licensee.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jaclyn Naves
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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