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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004120
Report Date: 06/28/2021
Date Signed: 06/28/2021 01:45:07 PM

Document Has Been Signed on 06/28/2021 01:45 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:TAN, SHUYIFACILITY NUMBER:
384004120
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Shuyi TanTIME COMPLETED:
11:24 AM
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On June 28, 2021 at 1:00 PM, Licensing Program Analyst(LPA) Lo and Cowan met with Licensee Shuyi Tan for an unannounced annual required inspection. Facility is currently not operating or providing care for children. Present today are Licensee and in-laws.

Per Licensee, the plan to apply for inactive status. LPA reminded Licensee to let our office know when that happens. Prior to beginning operation, Licensee is advised to renew First Aid CPR and Mandated Reporter Training, Training can be taken online: www.mandaterreporterca.com.
Incidental Medical Services (IMS) 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 Americans with Disabilities Act (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. Licensee was informed about the Provider Information Notices (PINs) on CCLD website. Safe Sleep handout and PINs were discussed. (REFER TO 809-C FOR CONT.)Licensee can also email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

>No Deficiencies were cited today under CRR, Title 22, Division 12, Chapter 3.

Copy of this report will be email to applicant. This report will be kept in the facility file and will be made available for public review upon request. Desk Duty is available Monday through Friday between 8 AM - 5 PM at (650) 266-8800

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Sheran Lo
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2021
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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