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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002976
Report Date: 10/07/2022
Date Signed: 10/07/2022 04:43:38 PM

Document Has Been Signed on 10/07/2022 04:43 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:XU, CHUNFACILITY NUMBER:
384002976
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Chun XuTIME COMPLETED:
05:00 PM
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 On October 7, 2022., Licensing Program Analyst (LPA) Van conducted an annual mandated inspection, including inspecting the facility's interior and exterior and reviewing the required childcare paperwork with the Licensee. LPA met the Licensee, Chun Xu. The purpose of the inspection was explained, and granted entry to the home by the Licensee. Today, four children (2 infants and 2 preschoolers) were supervised by Licensee. All adults living or working in the house have a criminal record clearance. The Licensee stated there are no changes to the physical plant, and all childcare areas remain the same. Day Care Areas: living room, dining room, and bathroom. Off-Limit Areas: the entire ground floor, back yard, the three bedrooms, and the kitchen on the second level. Hours of operations are Monday to Friday, 8:00 am - 5:30 pm. All restricted daycare areas have been appropriately blocked off from the children.
LPA toured and inspected the childcare areas for any health and safety hazards. The childcare space is clean and orderly, with age-appropriate activities, books, and play materials. Playpens and cribs are available for younger children, and cots are for older children to use for napping. LPA observed that an infant playpen has a blanket, pillows, and toys inside of it. LPA reminded the Licensee that there should be no toys, pillows, or objects hanging above the cribs/playpens per Infant Safe Sleep Regulation. All mattresses shall be designed for that cribs, and bedsheets should be tight-fitted.
The home has sufficient heating, lighting, and ventilation and is free of defects or risks that harm children in care. There are a fully charged fire extinguisher, smoke and carbon monoxide detectors, and a functional phone. Fully stocked first aid supplies are available for children. According to the Licensee, there are no firearms or weapons. There are no pools, spas, or other bodies of water on the premises. LPA did not observe any walkers, bouncers, or similar items in the home. Licensee acknowledges that smoking is prohibited in family childcare homes. The Licensee posted all the required forms, such as facility License, Notification of Parent's Rights, Earthquake Preparedness checklist, and Notification of Personal Rights. Continued on page 2...
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2022
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: XU, CHUN
FACILITY NUMBER: 384002976
VISIT DATE: 10/07/2022
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 The Licensee does not utilize the backyard. Per Licensee, she serves all breakfast, lunch, and morning and afternoon snacks. The Licensee stated the fire and drills are conducted at least once every six months, and the last drills were conducted on June 10, 2022.
LPA reviewed all of the children's records during the inspection. The Licensee maintains thorough records for all children, including vaccination records and Parent's Rights forms. LPA confirmed that each child has a complete emergency information card with the child's full name, phone number, and the location of a parent or authorized person who may be called in an emergency. The name and phone number of the child's doctor and the parent's permission for the Licensee to consent to emergency medical care. The Licensee has valid Pediatric FirstAid CPR good until September 2023 and has up-to-date Child Care liability insurance through Markel.
During the inspection, LPA requested the Licensee submit up-to-date immunization records and Mandated Reporter Training to the Licensing Office by October 21, 22.
LPA discussed the safe sleep regulations with the Licensees and 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 registering all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
The 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: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
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: XU, CHUN
FACILITY NUMBER: 384002976
VISIT DATE: 10/07/2022
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 The 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. Licensees were 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, Licensee must have proof of completion of EMSA-certified lead poison training if applying for a change of location or capacity to an existing license.
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.
The report was reviewed and signed by Licensee Chun Xu. No deficiencies were observed or cited today. Today's report and Site visit notice were provided to the Licensee. LPA informed the Licensee that a site visit notice must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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