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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004309
Report Date: 07/07/2021
Date Signed: 07/07/2021 02:37:35 PM

Document Has Been Signed on 07/07/2021 02:37 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:CHEN, TIANYANFACILITY NUMBER:
384004309
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
07/07/2021
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:20 AM
MET WITH:Tian Yan Chen (Ada)TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA ), Mok, conducted an case management inspection to add a backyard to the daycare area. There were 6 children that included 3 infants with a licensee's husband present. All adults have fingerprint clearance. LPA inspected the backyard for health and safety hazards. There were a gate that is stabled to the wall. There was no harmful objects in the yard. All the sharp corners and concrete base were covered. The backyard is approval and added to the daycare areas today.
















This report was provide to licensee via email.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Cindy Mok
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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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