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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004214
Report Date: 12/20/2022
Date Signed: 12/20/2022 02:31:34 PM

Document Has Been Signed on 12/20/2022 02:31 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:WU, XUE XIAFACILITY NUMBER:
384004214
ADMINISTRATOR:WU, XUE XIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 691-9966
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
12/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Xue Xia WuTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Yee conducted an Unannounced Required - 1 Year inspection to this family child care home today. Present at the facility are the Licensee, Xue Xia, helper (sister), and 8 children. The purpose of the inspection was explained. The facility personnel summary report was reviewed with Xue Xia and she said it's correct. Current residents are licensee, Xue Xia, her husband, and their 2 children ages 3 years old, 7 years old. The facility operation hours are Monday - Friday, 8:00 am - 6:00 pm.

Daycare areas are Classroom #1, #2, #3, bathroom, and backyard. The remaining areas of the home are off-limits.

The home is clean orderly and properly ventilated. The home is equipped with a fully charged fire extinguisher size 2A10BC, a smoke detectors, and a carbon monoxide. Smoke detector and carbon monoxide are in working condition. There are no bodies of water in the premises. All harmful objects such as sharp, chemicals, detergents, cleaning compounds, medication are made inaccessible to children in care. Kitchen/Bathroom cabinets/drawers have child protective locks in place making all sharp objects or toxic household items inaccessible to children. First aid supplies are available for children. The facility conducts fire drills/earthquake drills and was properly logged (11/29/22). The disciplinary policy was discussed with Licensee today. The home has age-appropriate toys and equipment available for the children in care.

LPA reviewed the children's files and staff records during the visit. Staff records are in order.

continue to the next page.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: WU, XUE XIA
FACILITY NUMBER: 384004214
VISIT DATE: 12/20/2022
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Licensee’s CPR and 1st aid certificate is current and will expire on 05/1/2023.

LPA discussed Child Abuse Mandated Reporter Training AB1207 with Licensee. As of January 1, 2018, all staff will be required to complete Child Abuse Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. The licensee completed AB1207 on 11/07/2021.

LPA discussed the safe sleep regulations with the 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 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. A sample of an infant sleep chart was provided.

Notice of Site Visit posted and shall remain posted for 30 days.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: WU, XUE XIA
FACILITY NUMBER: 384004214
VISIT DATE: 12/20/2022
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Licensee’s CPR and 1st aid certificate is current and will expire on 12/10/2024.

LPA discussed Child Abuse Mandated Reporter Training AB1207 with Licensee. As of January 1, 2018, all staff will be required to complete Child Abuse Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. The licensee completed AB1207 on 12/28/2021.

LPA discussed the safe sleep regulations with the 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 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. A sample of an infant sleep chart was provided.

Notice of Site Visit posted and shall remain posted for 30 days.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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