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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004430
Report Date: 06/23/2021
Date Signed: 06/23/2021 02:43:04 PM

Document Has Been Signed on 06/23/2021 02:43 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:LIU, YAN LIFACILITY NUMBER:
384004430
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/23/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Yan Li LiuTIME COMPLETED:
01:00 PM
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On June 23, 2021 at approximately 11:35am, Licensing Program Analyst (LPA) Winnie Ly, conducted a scheduled Pre-Licensing inspection and met with Applicant, Yan Li Liu. LPA and Applicant inspected the entire home for Health and Safety Hazards. Applicant rent the apartment unit and resides here with her husband. Adults in the home have criminal record clearance on file.

Day Care Areas are living room, dinning room, a bedroom and the bathroom. Off Limit Areas are the entire upstair which consists of a bedroom and bathroom. Applicant’s CPR/First Aid expires 04/2023. Applicant has Completed Mandated Reporter Training.

LPA observed the home is clean orderly and properly ventilated. Telephone service, heating, lighting and ventilation were evaluated. LPA observed a 2A10BC Fire extinguisher, operable smoke detector and carbon monoxide in the kitchen area. LPA observed no bodies of water nor fireplace in the home. Electrical outlets have child protective covers in place making them inaccessible to children. Chemical, detergents, cleaning compounds, medications, and other items of this nature are made inaccessible to children. Kitchen/Bathroom cabinets/drawers have child protective covers in place. Per Licensee, home does not have firearms or dangerous weapons.

Home has age appropriate toys and equipment available for the children in care. Applicant is reminded of NO walker, exersaucers, jumpers, bouncers and any similar items to be used for children in care. Those items shall be made inaccessible to children. Discipline policy was discussed with applicant.

Applicant is also been advised all adults, 18 years and older living in the home, helper, or assistant must have criminal background clearance and must be associated to the facility by submitting an LIC 9182 with copy Ca. ID prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day.

CONTINUED>>>
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2021
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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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: LIU, YAN LI
FACILITY NUMBER: 384004430
VISIT DATE: 06/23/2021
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Applicant is not considering providing Incidental Medical Services (IMS) to children at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

Applicant was also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

LPA discussed Child Abuse Mandated Training AB1207 with Applicant. As of January 1, 2018 all staff will be required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

This report is discussed and explained to the Applicant. Records to be Maintain in the facility is explained and left with the Applicant to be used for all children in care. Mandatory Posting Requirements: License, Emergency Disaster Plan, and Notification of Parent's Rights Poster. A copy of A Child Care Provider’s Guide to Safe Sleep and Lead Poisoning Facts were also provided to the Applicant.

This report will be kept in the facility file and will be made available for public review upon request. Desk duty is available M-F, 8a.m.-5p.m., (650) 266-8800. Website for forms and Regulations: www.cdss.ca.gov

Small Family Child Care License is approved and will be effective as of today, 06/23/2021.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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