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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004254
Report Date: 07/27/2021
Date Signed: 07/27/2021 02:17:53 PM

Document Has Been Signed on 07/27/2021 02:17 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, SHUNAFACILITY NUMBER:
384004254
ADMINISTRATOR:LI,SHUNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 988-5799
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94158
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
07/27/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Li ShunaTIME COMPLETED:
02:30 PM
NARRATIVE
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On July 27, 2021, at 11:00 am, Licensing Program Analysts (LPAs) Van and Bilingual Cantonese & Mandarin (LPA) Ly met with the Licensee, Li Shuna, for a subsequent complaint investigation. Due to the Licensee's limited English, LPA Ly was assisting with the translation. There were six children in care today, three infants and three preschoolers with two helpers.

During the complaint visit, LPAs reviewed the children's records. Based on children records reviewed, LPAs found that multiple records were missing Immunization. As a result, the following Title 22 deficiency is being cited on the next page.

The report was reviewed and signed by the Licensee, Shuna Li. Today's report, 7/27/2021, and notice of site visit will be sent to the Licensee email by the close of business on 7/27/21. Confirmation of receipt is required.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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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Document Has Been Signed on 07/27/2021 02:17 PM - It Cannot Be Edited


Created By: Brendon Van On 07/27/2021 at 01:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LI, SHUNA
FACILITY NUMBER: 384004254

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2021
Section Cited
CCR
102418(g)

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102418 Immunizations (g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
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Licensee shall maintain all children's immunization records and keep them in the children's file. The Licensee stated she would contact parents, obtain the Immunization for the missing children, and provide the copy of an up to date immunization to LPA by 8/6/21.
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This requirement is not as evidence by the children's records reviewed. Children records review revealed that multiple children were missing Immunization on their file. This poses a potential risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Garfield Leung
LICENSING EVALUATOR NAME:Brendon Van
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2021


LIC809 (FAS) - (06/04)
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