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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002976
Report Date: 05/30/2023
Date Signed: 05/30/2023 04:54:35 PM

Document Has Been Signed on 05/30/2023 04:54 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:XU, CHUNFACILITY NUMBER:
384002976
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
05/30/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Chun XuTIME COMPLETED:
05:00 PM
NARRATIVE
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On May 30, 2023., Licensing Program Analyst (LPA) Van met with Licensee Xu Chun for an announced case management inspection. The inspection purpose was to process a capacity increase requested by the Licensee. The Licensee supervised 5 children today (3 infants and 2 preschool-age children). The children were napping during the visit. All adults living and working at the home have fingerprint clearance on file. Per Licensee, there were no changes in the physical plant. All childcare and off-limit areas are the same. The hours of operation will be Monday through Friday, 9:00 am – 5:00 pm. This facility has applied for a capacity increase from 8 to 12 children.

LPA inspected the childcare areas for health and safety hazards. The home is clean and orderly and has sufficient lighting and ventilation. The fire extinguisher is fully charged and meets the requirement. The facility has a smoke detector, carbon monoxide detector, fully charged fire extinguishers, and a working telephone. Licensee, there are no guns or weapons in the home. LPA observed that the home has age-appropriate toys and equipment available for the children.

The following deficiencies were observed during the inspection. LPA observed that cleaning product/disinfectant spray bottles were accessible to children under the bathroom cabinet. Licensee did not maintain an infant sleeping documentation of the check every fifteen minutes. In addition, blankets and pillows were observed inside an infant's playpen. During the annual inspection on October 7, 2022, the same thing was observed, and LPA had then informed and provided safe infant sleep to the Licensee.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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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Document Has Been Signed on 05/30/2023 04:54 PM - It Cannot Be Edited


Created By: Brendon Van On 05/30/2023 at 02:43 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: XU, CHUN
FACILITY NUMBER: 384002976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/30/2023
Section Cited
CCR
102417(g)(4)

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102417 Operation of a Family Child Care Home (g)The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not be limited to: (4)Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.This requirement is not met as evidenced by:
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The Licensee must ensure that disinfectant and cleaning products are stored inaccessible to children. The Licensee plans to purchase a child-proof latch for the cabinet sink. Although LPA informed the Licensee such products should be kept away • The Licensee must ensure that disinfectant and cleaning products are stored inaccessible to children. The Licensee plans to purchase a child-proof latch for the cabinet sink. Although LPA informed the Licensee such products should be kept away from the children, the Licensee did not take any action or remove the cleaning products and place them in the off-limit areas. LPA had to request that the License remove the cleaning products and store them in the off-limit area. Licensee then proceeded to remove the cleaning products. The deficiency has been cleared.
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Based on observations, LPA confirmed that the Licensee had accessible disinfectant praying bottles under the sink cabinet in the bathroom. This poses an immediate health and safety risk to children in care.
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Type B
06/09/2023
Section Cited
CCR102425(j)(2)

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102425(j)(2)The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
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Based on the record review, the Licensee did not comply with the section cited above in 3 out of 3 infants did not have documented sleep checks, posing a potential health, safety or personal rights risk to persons in care.
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Licensee must ensure that the 15-minute check must be documented with an initial. The License agrees to document the sleep checks for all infants under 24 months old and email to LPA by the stated date.
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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:Garfield Leung
LICENSING EVALUATOR NAME:Brendon Van
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/30/2023 04:54 PM - It Cannot Be Edited


Created By: Brendon Van On 05/30/2023 at 03:14 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: XU, CHUN
FACILITY NUMBER: 384002976

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/09/2023
Section Cited
CCR
102425(b)

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102425(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
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The Licensee must ensure and adhere to the infant's safe sleep regulation in that no loose objects, such as blankets, pillows, and toys, are inside the infant cribs/play yards during napping.
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Based on observations, LPA confirmed that loose objects, such as blankets and pillows, were inside the infant play yard. This poses a potential health and safety risk to children in care.
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Proof of correction will be submitted to the department via email.

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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.
SUPERVISOR'S NAME:Garfield Leung
LICENSING EVALUATOR NAME:Brendon Van
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2023


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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: XU, CHUN
FACILITY NUMBER: 384002976
VISIT DATE: 05/30/2023
NARRATIVE
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During the inspection, LPA informed/discussed with the Licensee the following:

· All 18 yrs and older adults living in the home or working at the house must have fingerprint clearance before contacting the children
· LPA reviewed the Large license capacity requirements with the Licensee.
· Licensee was informed that Licensee and all helpers must have valid Pediatric FirstAid CPR for a large license.
· Mandated Reporter Training. Training must be completed every two years, and training can be taken online at www.mandatedreporterca.com
· Safe-Sleep; Individual Infant Sleeping Plan; and required documentation of the infant sleep check.
· Infant walkers, exersaucers, jumpers, baby bouncers, and similar items are prohibited in the daycare.
· Records to be maintained in the facility were explained—mandatory Posting requirements: License, Emergency Disaster Plan, and Notification of Parents' Rights Poster.
· Reporting Requirements.

Large family child care home capacity increase will be approved upon Fire Department clearance, STD 850, and a complete plan of correction for the deficiencies cited today.

See LIC 809D for deficiencies cited today. Today's report, deficiencies, appeal rights, and site visit notice were printed and provided to the Licensee. LPA informed the Licensee to provide a copy of this licensing report dated May 30, 2023 that documents any Type A citation to parents/guardian of all children 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. In addition, LPA also informed the Licensee that a site visit notification must be 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: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
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