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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004190
Report Date: 05/01/2024
Date Signed: 05/01/2024 11:32:56 AM

Document Has Been Signed on 05/01/2024 11:32 AM - 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:KONG, XIAO JIAOFACILITY NUMBER:
384004190
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
05/01/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Xiao Jiao KongTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On May 01, 2024 at approximately 11:00am, Licensing Program Analyst (LPA) Ly conducted a Plan of Correction (POC) Visit to this family child care home and met with Licensee Xiao Jiao Kong. Purpose of visit was explained. Present during the visit was just Licensee caring for 2 preschool age children and 2 infant age children.

The POC is regarding Type B deficiencies cited on 04/03/2024 sign as a form of advertisement posted on window does not have license number and facility did not have children roster for review.

On this day, based on LPA's observation and file review, Licensee removed sign from window and licensee has updated children roster on file. LPA cleared Type B deficiencies cited on 04/03/2024 and letter of clear deficiencies provided to Licensee.

A copy of this report and appeal rights were discussed and left with Licensee whose signature on this form confirm receipt of these reports.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2024
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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