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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004193
Report Date: 10/13/2021
Date Signed: 10/13/2021 01:27:02 PM

Document Has Been Signed on 10/13/2021 01:27 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:LI, XIAO JUANFACILITY NUMBER:
384004193
ADMINISTRATOR:LI, XIAO JUANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 517-2821
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
10/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:LI, XIAO JUANTIME COMPLETED:
01:30 PM
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On October 13, 2021, Licensing Program Analyst (LPA), Van, conducted an unannounced annual inspection and met with Licensee Li, Xiao Juan. The purpose of the inspection was explained and granted entry to the home by the Licensee. There are nine children in care with Licensee and two helpers. Another child arrived during the inspection. All adults living in the home or working at the daycare have cleared criminal records. Day Care Area is provided on the first level only. The daycare areas consist of a playroom, bathroom, and backyard. Off Limit Areas are a sun-room, the garage on the first floor, and the second floor. Days and hours of operations are Monday – Friday from 7:30 am – 6:00 am. Per Licensees, sick children will be separated from the group and waiting for the parent to pick them up in the hallway by the main entrance.

LPA and Licensee inspected the daycare areas for health and safety hazards. During the inspection, LPA observed the following: The daycare area is clean, orderly, and equipped with age-appropriate toys and equipment for the children. The home has adequate lighting and ventilation. The house has a working smoke alarm, carbon monoxide detector, and a fully charged fire extinguisher. The backyard is observed clean, children's toys and climbing/play structures are sturdy; Licensee installed rubbers cushion on the backyard floor to help absorb children's falls. First aid supplies are available for children. Per Licensee, there are no firearms, weapons, or pets in the home. LPA observed no pools, spas, or other bodies of water on the premises. The Licensee had posted all the required forms (i.e., License, Notification of Parent's Rights, Earthquake preparedness checklist, and Notification of Personal Rights). Per Licensee, fire drills are conducted every six months, and a record was kept accordingly.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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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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: LI, XIAO JUAN
FACILITY NUMBER: 384004193
VISIT DATE: 10/13/2021
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During the inspection, LPA reviewed ten children's records and all staff records. LPA observed that the Licensee maintained records of each child accordingly; identification and emergency information, consent for medical treatment, and parent's rights were appropriately completed. The Licensee and helpers have maintained a record of immunization, mandated reporter training certification, and Licensee CPR&FirstAids training is valid.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at 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 they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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.

Incidentals 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: http://www.ada.gov/childqanda.htm
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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: LI, XIAO JUAN
FACILITY NUMBER: 384004193
VISIT DATE: 10/13/2021
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The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a child care 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 Licensee. 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.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

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.



No deficiencies were observed in today's inspection. The report was reviewed and signed by the Licensee, Li Xiao Juan. Today's report, 10/13/2021, and notice of site visit will be sent to the Licensee email at happyamye@yahoo.com by the close of business on 10/13/2021. Confirmation of receipt is required, and a notice of site visit must remain posted for 30 days.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC809 (FAS) - (06/04)
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