384004193-12-16-2024-05-CC-JNAS-DBZRPH-20241216121159

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004193
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:12:20 PM

Document Has Been Signed on 12/16/2024 12:12 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	LI, XIAO JUAN		FACILITY NUMBER:	384004193
ADMINISTRATOR/ DIRECTOR:	LI, XIAO JUAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 517-2821
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 12	CENSUS: 9	DATE:	12/16/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:50 AM
MET WITH:	Xiao Juan Li		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On Monday December 16th,2024 at approximately 8:50 am Licensing Program Analysts (LPAs) Naves and Van conducted an unannounced annual visit. Lpa's met with Licensee Xiao Li and explained the purpose of the visit. Licensee allowed entrance Lpas observed 9 children (2 infant 7 preschool aged children) and 2 additional helpers. Licensee has a large license all staff present per Guardian have criminal record clearance. LPAs and licensee inspected the home and outdoor area for any health and safety concerns. Home had adequate lighting and heating and was equipped with fire detector and carbon monoxide detector. Home had charged Fire extinguisher meeting minimum requirement of 3A 40 BC. LPAs observed age appropriate toys and no toys were damaged or in need of repair. Home was clean and free of clutter or any safety risks. No cribs or play pens were visible, licensee stated all children sleep on cots with bedding provided by parents. Licensee showed sleep log for all infants under 2 years of age 15 minute checks are well documented. Outdoor area is fenced off and has covered and cushion flooring as well as undamaged play structure. No bodies of water or swimming pools were observed by LPAs. LPAs observed all required postings where parents can easily view. Last time emergency drill was conducted on 12/9/2024 and logged licensee conducts them every 3 months. Breakfast lunch and snacks are provided for children in care, no children have any knows allergies and no medications are given. Continued page 2..

Ali Zebila	TELEPHONE: (650) 266-8817
Jaclyn Naves	TELEPHONE: (650) 266-8800
	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LI, XIAO JUAN	FACILITY NUMBER: 384004193
	VISIT DATE: 12/16/2024

NARRATIVE

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Bathroom was clean with no accessibility to any cleaning products or hazards within children's reach. All electrical outlets were properly covered and no loose wires were seen.

A review of all staff present records was done all staff had current Mandated Reporter training and First Aid cpr current as well as immunization records. A review of 6 random children's files were done with all required forms filled out. Licensee has current liability childcare insurance. No guns or weapons are in the home and there is no smoking in the house as confirmed by licensee.

When a child becomes sick during care licensee has designated covered outdoor hallway where child will be isolated and has adequate ventilation until parent arrives.

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.

LPAs 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. LPAs 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.

continued page 3..

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jaclyn Naves	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LI, XIAO JUAN	FACILITY NUMBER: 384004193
	VISIT DATE: 12/16/2024

NARRATIVE

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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. Licensee was 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.

LPAs 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.

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.

continued page 4..

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jaclyn Naves	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LI, XIAO JUAN	FACILITY NUMBER: 384004193
	VISIT DATE: 12/16/2024

NARRATIVE

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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 was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, Xiao Li, confirmed that there are no Registered Sex Offenders living in the facility, and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

An exit interview was conducted, and the report was reviewed with the licensee,Xiao Li.

SUPERVISOR'S NAME: Ali Zebila	TELEPHONE: (650) 266-8817
LICENSING EVALUATOR NAME: Jaclyn Naves	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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