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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002423
Report Date: 12/16/2025
Date Signed: 12/16/2025 03:53:12 PM

Document Has Been Signed on 12/16/2025 03:53 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:YAN, XIAO LINGFACILITY NUMBER:
384002423
ADMINISTRATOR/
DIRECTOR:		YAN, XIAO LINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 830-1191
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
12/16/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:04 PM
MET WITH:Xiao Ling YanTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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On 12/16/2025, Licensing Program Analyst (LPA) J. Badger arrived at the above-named facility to conduct an unannounced annual inspection.

LPA was granted entrance and met by Licensee, Xiao Ling Yan, the LPA explained the purpose of the inspection. Present in the facility were the Licensee, one helper, three infant children and one preschool aged child.

The facility was found to be operating within capacity limits on this day. All adults living and working in the home are fingerprint cleared and associated, confirmed through a check on the CDSS Guardian Background Check System.

The hours of operation are Monday to Friday, 8:00 am - 5:30 pm.

DAY CARE AREAS: Located in the lower unit of the home, areas include a Kitchenette Living Room, Dining Room, one bedroom, and one bathroom.

OFF-LIMIT AREAS: The entire top level of the home.

Meals and snacks are prepared on-site and provided by the licensee.

LPA inspected day-care areas for health and safety hazards. LPA observed the home to be clean and in good condition. The air quality was comfortable and cool, and the temperature and ventilation were proper.

There was a variety of age-appropriate toys and equipment in the home, which were in good condition. No fireplaces were observed in day-care areas. There are no pools or bodies of water on the premises. During an inspection of the physical plant, LPA observed the bathroom cabinet near the toilet did not have a child lock, and there was a bottle of detergent in the unlocked cabinet.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2025
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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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 12/16/2025 03:53 PM - It Cannot Be Edited


Created By: Jovanna Badger On 12/16/2025 at 03:32 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: YAN, XIAO LING
FACILITY NUMBER: 384002423

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2026
Plan of Correction
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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.
Daniel J Oquendo
NAME OF LICENSING PROGRAM MANAGER:
Jovanna Badger
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2025


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: YAN, XIAO LING
FACILITY NUMBER: 384002423
VISIT DATE: 12/16/2025
NARRATIVE
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LPA asked the licensee to put a child safety lock on the bathroom cabinet. All cleaning supplies, poisons, and other chemicals were stored out of reach of children. A type B violation was issued.

LPA observed one play yard in the hall near the nap room, with one infant sleeping with a blanket covering them. In addition, the LPA also observed two cribs in the napping / playroom. Each crib had a child napping with a blanket. LPA asked the licensee to remove the blankets from the cribs and pack and play. The licensee was able remove all objects from the crib. A type B violation was issued.

The children sleep, under the supervision of the Licensee and helper in the napping / playroom.

There was a fully charged 2A10BC fire extinguisher, a smoke detector and a carbon monoxide detector, that were found to be in working condition. There is a working telephone on site. The phone number listed for the Licensee are current. LPA confirmed the licensee’s email address. Per Licensee, there are no weapons or firearms in the home.

LPA reviewed four children's records. LPA also reviewed facility records of the licensee and their helper.

Per the Licensee, there are no children enrolled with medication.

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)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.

Xiao Ling Yan, was reminded that all adults 18 and over living or working in the home, 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.

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NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
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: YAN, XIAO LING
FACILITY NUMBER: 384002423
VISIT DATE: 12/16/2025
NARRATIVE
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LPA discussed the safe sleep regulations with Xiao Ling Yan, 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 licensee of the importance of checking for and removing any 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.

The licensee was informed of the MyChildCarePlan.org website; 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

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Exit interview conducted, and report was reviewed with the Licensees, Xiao Ling Yan.

During the exit interview, Licensee Xiao Ling Yan, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Appeal rights were printed and given to the licensee, Xiao Ling Yan.

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

NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Jovanna Badger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025
LIC809 (FAS) - (06/04)
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