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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002432
Report Date: 09/06/2022
Date Signed: 09/06/2022 01:55:51 PM

Document Has Been Signed on 09/06/2022 01:55 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:CHEN, SHAO XIAFACILITY NUMBER:
384002432
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
09/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Shao Xia ChenTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Yee conducted an Unannounced Required - 1 Year inspection to this family child care home and met with Licensee, Shao Xia, husband and 5 children. The purpose of the inspection was explained. Days and hours of operations are Monday - Friday, 8:00 AM - 5:30 PM.

Daycare areas are: living room, kitchen, bedroom #1 next to the living room, hallway bathroom and backyard. The remaining areas are off limit. Licensee’s CPR expires 04/03/2023.

The home is clean orderly and properly ventilated. The facility has a 2A10BC Fire extinguisher, operable smoke detectors and carbon monoxide. All harmful objects such as sharp items, chemical, detergents, cleaning compounds, medications, and other items are made inaccessible to children. First aid supplies are available for children. Facility conducts fire drills/earthquake drills was properly logged. Disciplinary policy was discussed with Licensee today. Home has age appropriate toys and equipment available for the children in care.

LPA reviewed children's files and the files are in order.

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 reviewed Licensee and assistant files, Child Abuse Mandated Reporter Training were completed on 3/27/2021, 3/31/2021.

This family child care home provides Incidental medical Services-IMS. This facility provides Incidental Medical Services - IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children's, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 102417. 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. A written IMS is on file.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
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: CHEN, SHAO XIA
FACILITY NUMBER: 384002432
VISIT DATE: 09/06/2022
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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 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.

This report is reviewed with facility representative and a copy of this report must be made available for public review upon request.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
LIC809 (FAS) - (06/04)
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