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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004193
Report Date: 11/17/2022
Date Signed: 11/17/2022 12:14:12 PM

Document Has Been Signed on 11/17/2022 12:14 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:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Xiao Juan LiTIME COMPLETED:
12:30 PM
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On November 17, 2022, Program Analyst (LPA) Van performed an unannounced mandated annual inspection and met with Licensee XiaoJuan Li. LPA explained the objective of the inspection and was granted access to the property by the Licensee. There are nine children in care with Licensee and two helpers. The Licensee complies with the licensing capacity and limits today. All adults who live or work in the house have a criminal background check. The physical plant has not changed. The off-limits and childcare areas are the same. 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 sunroom, the garage on the first floor, and the entire second floor. Days and hours of operations are Monday – Friday from 7:30 am – 6:00 am.

LPA examined and inspected the Licensee's indoor and outdoor play spaces for health and safety concerns. The childcare environment is clean and organized, with age-appropriate activities, books, and play materials. The home has proper heating, lighting, and ventilation, and it is free of defects or situations that risk children in care. The house has a fully charged fire extinguisher, smoke and carbon monoxide detectors, and a functional phone. The facility has a fully stocked first aid kit available for children. LPA observed a crib in a nap room. LPA advised the Licensee that no toys, pillows, or anything else should be hung over the cribs/playpens. LPA observed that the mattress is the right size and has a fitted sheet. A child-proof cover protects every unused electrical outlet.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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: LI, XIAO JUAN
FACILITY NUMBER: 384004193
VISIT DATE: 11/17/2022
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According to the Licensee, there were no firearms, weapons, or pets on the premises, and no baby walkers, bouncers, or similar equipment in the daycare. The Licensee is informed that smoking is not permitted in family childcare facilities. According to the Licensee, the facility conducts fire and earthquake quarterly, and the latest drills were conducted on 10/7/2022. The facility offers breakfast, lunch, and two snacks.

During the inspection, LPA reviewed all children's records. The Licensee maintains thorough records for all children in their care, including vaccination records and Parental Rights forms. LPA noted that each kid had a complete emergency information card that included 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 and helpers kept up with their immunizations, Mandated Reporter Training, and had proper daycare liability insurance. Pediatric CPR/First Aid for Licensee and helpers are valid. The Licensee posted all required paperwork, such as the facility License, Notification of Parental Rights, Earthquake Preparedness Checklist, and Notification of Personal Rights.

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.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
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: LI, XIAO JUAN
FACILITY NUMBER: 384004193
VISIT DATE: 11/17/2022
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LPA discussed the safe sleep regulations with the Licensees and discussed 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 they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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, Licensees must have proof of completion of EMSA certified lead poison training if applying for a change of location or capacity change to an existing license.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
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: LI, XIAO JUAN
FACILITY NUMBER: 384004193
VISIT DATE: 11/17/2022
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LPA encouraged the Licensee to visit the 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.

Licensee XiaoJuan Li read and signed the report. During today's inspection, no deficiencies were discovered. Today's report and site visit notice were provided to the Licensee. LPA 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: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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