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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002737
Report Date: 06/15/2023
Date Signed: 06/15/2023 04:21:28 PM


Document Has Been Signed on 06/15/2023 04:21 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:LEE, WING K.FACILITY NUMBER:
384002737
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
06/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Wing LeeTIME COMPLETED:
04:25 PM
NARRATIVE
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On 6/15/2023 at 1:50PM., Licensing Program Analysts (LPA), Luis J. Gomez met with Licensee, Wing Lee. Purpose of the inspection was explained and was for an Unannounced; Annual Random inspection. Present in facility was the licensee and licensee’s wife caring for six children (3 preschool age, 3 infant age). Adults have criminal record clearances on file. Licensee’s home is a three bedroom, two bathroom, one level unit. Days and Hours of operations are: Monday – Friday, 8:00AM., to 6:00PM. Day-care Areas: Living Room #1 (Playroom), Bathroom #1, and Bedroom #1. Off-limit Area: Bedrooms #2, #3, Bathroom #2, Kitchen, Back Patio, and Living Room Area #2. LPA inspected facility with licensee, for health and safety hazards.

At 1:55PM., the following was observed: Facility was clean, orderly, with age-appropriate playthings available for the children. Floors and ground surfaces were clear of obstructions or hazards. Accessible furniture, toys and books inspected were in good repair. For napping services, LPA observed several cot and infant cribs (with tight-fitting sheet) stored in facility. Per licensee, napping sheets are washed weekly. Off-limit area have been made inaccessible with child safety gates installed. Bathroom #1 was maintained clean with adequate supplies for hand washing. Fixture were in operating condition. Facility was the proper temperature, with ventilation and lighting. Home had functioning telephone service, smoke detector, and carbon monoxide detector and fully charged fire extinguisher (2A:10BC).

Facility does not have any pools, fishponds, jacuzzi, or bodies of water.
(REFER TO 809C, FOR CONT)
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
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 6


Document Has Been Signed on 06/15/2023 04:21 PM - It Cannot Be Edited

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: LEE, WING K.
FACILITY NUMBER: 384002737

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 3:05PM., Based on record review, LPA confirmed 'Individual Infant Sleeping Plan', (LIC9227) missing for qualifying infant in care. This poses a potential health and safety risk to children in care.
POC Due Date: 06/22/2023
Plan of Correction
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Licensee will be have required LIC9227, for qualifying infant, C1, stored in children's files. Proof of correction will be submitted to the department via email.
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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At 2:55PM., Based on record review and interview, LPA confirmed licensee is not documenting infant napping conditions during each 15 minutes review. This poses a potential health and safety risk to children in care.
POC Due Date: 06/22/2023
Plan of Correction
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Licensee will begin to document napping conditions during each 15 minutes review for all infants in care. Proof of correction will be submitted to the department via email.
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 ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6


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: LEE, WING K.
FACILITY NUMBER: 384002737
VISIT DATE: 06/15/2023
NARRATIVE
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(Page 2)
At 2:30PM, LPA reviewed facility and children’s records. Children’s files were reviewed and included the: Identification of Emergency Information (LIC700); Immunization Record; Notification of Parent's Rights (LIC995); and Consent for Medical Treatment (LIC627).

At 2:55PM., Based on record review and interview, LPA confirmed licensee is not documenting infant napping conditions during each 15 minutes review.



At 3:05PM., Based on record review, LPA confirmed 'Individual Infant Sleeping Plan', (LIC9227) missing for qualifying infant in care.

LPA reminded licensee to renew the required Cardiopulmonary Resuscitation (CPR)/ First Aid certification.

LPA reminded licensee to conduct, and document emergency disaster drills once every 6 months. Advisory Note: Technical Assistance (LIC9102TA) was issued.

Required posting are posted, including Childcare License, Notification of Parent’s Rights (PUB379), Emergency Disaster Plan (LIC610A). Per licensee, isolation of an ill children is in the playroom.

LPA advised licensee to ensure all children’s meal containers brought by families must be labeled. Per licensee, home does not have any firearms.

Licensee was reminded all adults, 18 years and over, living or working in the home, including employee and volunteers, must obtain criminal 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.


(REFER TO 809C, FOR CONT.)
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LEE, WING K.
FACILITY NUMBER: 384002737
VISIT DATE: 06/15/2023
NARRATIVE
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(Page 3)
LPA discussed the safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.

Based on today's inspection, deficiencies were observed in areas evaluated according to California Title 22, Div. 12 Chap. 3 Health and Safety Code of Regulations, and cited on 809-D. In exit interview, Plan of correction, evaluation report was discussed with Wing Lee, and the licensee’s signature of this form acknowledges receipt of these documents.

Notice of Site Visit was provided and must remain posted for 30 days.
SUPERVISOR'S NAME: Ali ZebilaTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Luis GomezTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6