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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004394
Report Date: 05/07/2021
Date Signed: 05/07/2021 01:17:28 PM

Document Has Been Signed on 05/07/2021 01:17 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,HUGHFACILITY NUMBER:
384004394
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
05/07/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hugh LiTIME COMPLETED:
11:00 AM
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Licensing Program Analyst, LPA Yee conducted a virtual inspection today. Current residents are Hugh Li and his 13 years old son. The 13 years old son stays with him on the weekend only. The applicant has a fingerprint clearance on file. Days and hours of operation: Monday to Friday between 9:00 AM to 5:00 PM.

Day Care Areas: living room, and bathroom. Off-limit areas: applicant's bedroom, son's bedroom, kitchen, front yard, and back yard. The home is leased and the lease agreement is on file. The home has a carbon monoxide detector, smoke detector, and fire extinguisher. LPA advised the applicant to conduct emergency drills once every six months and keep a log sheet.

The applicant has required immunization records on file. CPR and 1st aid are current until 11/2022. 8 hours Health and Safety certificate was completed on 11/21/2020.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an 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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, Available at http://www.ada.gov/childqanda.htm

LPA review AB 1207 with the Licensee. As of January 1, 2018, all staff is required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Licensee completed AB 1207 on 12/16/2020. A certificate is on file. The applicant has been advised that all adults living or working at the facility must have fingerprint clearance prior to having contact with children. He said He understands.

LPA discussed the safe sleep regulation concepts. A packet of records to be maintained and posting requirements were explained and provided. Website for forms and regulations: www.ccld.ca.gov.
COVID-19 Self-Assessment Guide and posting requirements were discussed.

A small license is approved effective today.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 05/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2021
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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