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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004254
Report Date: 08/27/2021
Date Signed: 08/27/2021 10:57:09 AM

Document Has Been Signed on 08/27/2021 10:57 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LI, SHUNAFACILITY NUMBER:
384004254
ADMINISTRATOR:LI,SHUNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 988-5799
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94158
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
08/27/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Li ShunaTIME COMPLETED:
11:15 AM
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On August 27, 2021, at 9:00 am, Licensing Program Analyst (LPA) Van met with the Licensee, Li Shuna, for an unannounced inspection of the Plan of Correction (POC). The purpose of the inspection was explained, and was granted entry to the home by Licensee. Present, there are five children in care with the Licensee, three infants and two preschoolers.

On August 19, 2021, the following deficiency was cited during the complaint inspection to deliver the findings. The Licensee did not comply with section 102416.5(d)(1) of the Regulation; Based on children's records review and interviews confirmed that the Licensee was caring for more than six infants in the month of June and July. In today's inspection, LPA observed that the Licensee operates within the infants limit of the License. Furthermore, the Licensee has submitted the children's weekly schedule to Licensing. A deficiency that was cited on August 19, 2021, is cleared today. Copy of Letter of Deficiency Citations will be sent to the Licensee.

An exit interview was conducted with the Licensee, and a consultation was provided. The Licensee, Li Shuna, signed the report. Today's report, 8/27/2021, and notice of site visit will be sent to the Licensee at selinali2288@gmail.com by the close of business on 8/27/21. Confirmation of receipt is required.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2021
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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