384002962-6-3-2025-05-CC-JTSE-DHB298-20250603171131

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384002962
Report Date: 06/03/2025
Date Signed: 06/03/2025 05:12:19 PM

Document Has Been Signed on 06/03/2025 05:12 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:	CHIBI CHAN TOO		FACILITY NUMBER:	384002962
ADMINISTRATOR/ DIRECTOR:	YIP, JENNIFER		FACILITY TYPE:	850
ADDRESS:	800 PRESIDIO AVE		TELEPHONE:	(415) 202-7905
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94115
CAPACITY: 36	TOTAL ENROLLED CHILDREN: 36	CENSUS: 21	DATE:	06/03/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:40 PM
MET WITH:	Site Supervisor, Jennifer Yip		TIME VISIT/ INSPECTION COMPLETED:	05:30 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 6/3/2025, at approximately 1:40PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA met with Site Supervisor, Jennifer Yip (D1), and explained the purpose of the visit. Present during the visit was D1, six staff members, and 21 preschool-age children. The facility is operating within staffing and ratio requirements on this day. Program Director Shoshana Kanzaki (D2) arrived at the facility at 4:15PM. The facility is located on the premises of Booker T. Washington Community Service Center. LPA and D1 inspected the facility for any health or safety hazards. There is a fully charged fire extinguisher that is at least size 2A10BC. There is a carbon monoxide detector present. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children in care. Emergency exits are clearly marked and visible. Evacuation routes are posted and accessible for review by staff. Waste bins are fitted with tight-fitting lids. There is a fully equipped first aid kit present. Electrical outlets are covered or blocked by furniture to be inaccessible. LPA observed age-appropriate toys and learning materials to be present. Furniture is age-appropriate and free of rough or sharp edges. There are cubbies available for each child to use. Children nap on cots and bring their own bedding from home. Bedding is brought home once a week for cleaning. Toilets and handwashing sinks were observed to be operational during the visit. Children bring lunch from home and the facility provides morning and afternoon snacks. The facility accommodates food allergies and dietary preferences. Medication is stored centrally and inaccessible to children in care. Continued on Page Two

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

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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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: CHIBI CHAN TOO	FACILITY NUMBER: 384002962
	VISIT DATE: 06/03/2025

NARRATIVE

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LPA observed the outdoor play area to be free of debris and other loose materials. It is enclosed by a fence that is at least four feet high. There is a play structure that is cushioned with resilient padding. The play area is rated for children from the ages of two to five. There is shade available from the building or umbrellas placed throughout the play area. Drinking water is readily accessible while children are outside. The facility has an outdoor rotation waiver that allows for up to 23 children to be outside at a time. The facility was observed to be in compliance with the waiver during the visit. There are no swimming pools or other similar bodies of water present. No firearms or weapons are stored in the facility.

LPA reviewed seven staff files, six children’s files, and facility records. LPA observed there to be at least one staff member with current Pediatric First/Aid CPR training on file. Mandated Reporter Training certificates, staff qualifications, and immunizations were made available for review.

LPA observed two staff members (S1 and S2) to not have fingerprint clearance or association to the facility during the visit. LPA observed that the LiveScan form that the facility used did not send fingerprints to the Department. LPA advised that the facility must use the most recent LiveScan request form (LIC9163). The most recent licensing forms can be found at https://www.cdss.ca.gov/inforesources/forms-brochures. LPA advised that the two staff members must get fingerprinted at a LiveScan vendor and may not return to the facility until they acquire fingerprint clearance. Two copies of LIC9163 were provided during the visit.

LPA informed D2 that a Type A deficiency and a civil penalty of $500 each would be assessed for S1 and S2 not acquiring fingerprint clearance prior to their presence at the facility.

LPA observed children’s files to contain Emergency Identification and Information (LIC700), immunization records, and Physician’s Reports (LIC701). Children are signed in digitally with Brightwheel.

The facility was issued a Type A deficiency during an annual visit on 6/26/2024. The facility is required to maintain signed copies of Acknowledgement of Receipt of Licensing Reports (LIC9224) in each child’s file. During the visit, LPA was unable to verify the presence of LIC9224 in each child’s file. LPA discussed the requirement to maintain this documentation and informed D2 that a Type B deficiency would be cited.

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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

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: CHIBI CHAN TOO	FACILITY NUMBER: 384002962
	VISIT DATE: 06/03/2025

NARRATIVE

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The facility last conducted an emergency drill on 4/16/2025. Emergency drills are properly logged and documented. The Booker T. Washington Community Center was constructed after 2010, and as such the facility is not required to test its fixtures for lead.

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.

Facility representative was reminded that all adults 18 and over, 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 Child Care Center. 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.

Assembly Bill (AB) 2370, Chapter 676, Statutes of 2018, requires all licensed Child Care Centers (CCCs) constructed before January 1, 2010, to test their water (used for drinking and food preparation) for lead contamination before January 1, 2023, and then every 5-years after the date of the first test. For child care center licenses issued after July 1, 2022, the licensee shall test their water for lead within 180 days of licensure pursuant to Written Directives section 101700 (PIN 21-21.1-CCP).

LPA referred facility representative to the Department website for lead: Lead Toxicity Prevention and Water Testing Information.

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 PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication. Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.
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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

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: CHIBI CHAN TOO	FACILITY NUMBER: 384002962
	VISIT DATE: 06/03/2025

NARRATIVE

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Facility representative 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.

See LIC809-D for deficiencies cited today regarding fingerprint clearance and Acknowledgment of Receipt of Licensing Report (LIC9224). See LIC9102-TV and LIC9102-TA for technical violations and technical assistance regarding staff records. Appeal rights were provided and explained. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with facility representative, Shoshana Kanzaki.

LPA Tse informed facility representative Shoshana Kanzaki that this report dated 6/3/2025 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, LPA Tse informed the facility representative to provide a copy of this licensing report dated 6/3/2025 that documents any Type A citations 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.

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/03/2025 05:12 PM - It Cannot Be Edited

Created By: Jonathan Tse On 06/03/2025 at 04:45 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: CHIBI CHAN TOO	FACILITY NUMBER: 384002962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1596.871(c)(1)(A)

Administration of Child Day Care Licensing

Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of seven staff members present, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/04/2025
	Plan of Correction
1 2 3 4	Licensee shall have S1 and S2 fingerprinted and submit proof of the receipt via email to LPA by 6/4/2025.

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.

	Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:

	Jonathan Tse
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/03/2025 05:12 PM - It Cannot Be Edited

Created By: Jonathan Tse On 06/03/2025 at 04:47 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: CHIBI CHAN TOO	FACILITY NUMBER: 384002962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8595(c)(1)

A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not maintaining documentation of signed LIC9224s in each child's file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2025
	Plan of Correction
1 2 3 4	Licensee shall provide all parents with a copy of today's report dated 6/3/2025 and have them sign and return form LIC9224. Five LIC9224s shall be submitted to LPA as proof that parents have received and signed the acknowledgement form.

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.

	Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:

	Jonathan Tse
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025

LIC809 (FAS) - (06/04)

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