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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004432
Report Date: 06/14/2022
Date Signed: 06/14/2022 04:41:13 PM

Document Has Been Signed on 06/14/2022 04:41 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, XIAO LIFACILITY NUMBER:
384004432
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Xiao Chen LiTIME COMPLETED:
04:45 PM
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On June 14, 2022, Licensing Program Analyst (LPA) Van performed an annual 1-year mandatory inspection, which included checking the interior and exterior of the facility and discussing the required childcare paperwork with the Licensee. Licensee Chen, XiaoLi and two infants are present. Children's capacity and ratio requirements were seen to be satisfied today. The licensee rents the house. The documentation of property control was requested during the visit. The childcare areas include the playroom, living room/dining room, bedroom #1, and bathroom. The Licensee's bedroom #2, and kitchen are all off-limits. All off-limit locations have been adequately gated. Days and operations are from Monday through Friday, from 8:00 am to 6:00 pm.

LPA inspected the facility's indoor and outdoor environments for health and safety purposes. The childcare area is clean and organized, with age-appropriate toys and equipment. Licensee acknowledges that no baby walkers, bouncers, exersaucers, or other similar items are permissible to be used during daycare hours. The house has sufficient lighting and ventilation. A functional telephone, working smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher are all present in the house. According to the Licensee, there are no bodies of water on the premises. LPA observed two baby cribs in the nap room. Both cribs have fitted sheets with appropriate mattresses specifically for the crib. There are no toys or blankets inside the cribs. Daycare children have no access to detergents, disinfectants, or cleaning chemicals. The Licensee claims there are no guns or weapons in the house. The licensee does not have a backyard.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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: CHEN, XIAO LI
FACILITY NUMBER: 384004432
VISIT DATE: 06/14/2022
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The Licensee's CPR and First Aid certification expires on March 2023. Emergency drills are held at least once every six months, and the last drills were conducted on 2/25/2022. All drills were appropriately logged/documented by the Licensee. The Licensee serves snacks and meals daily. Isolation of ill children was reviewed and discussed. The children's roster has been reviewed and found to be complete and up to date. Children's files were reviewed. The Licensee maintains thorough records for all children in their care, including vaccination records and Parental Rights forms. LPA noted that each kid had a complete emergency information card that included the child's full name, phone number, and the location of a parent or authorized person who may be called in an emergency. LPA discussed care and supervision with the Licensee. There is no transportation provided. Capacity options were reviewed, and the Licensee acknowledges that care cannot be provided over the capacity specified on the license. The requirements for reporting suspected child abuse, as well as reporting requirements for unusual incidents, were discussed. All mandatory postings are posted (License/Parent's Rights poster/Emergency Disaster Plan and Earthquake Preparedness Checklist).

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with the Licensees and discussed the Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the Licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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: CHEN, XIAO LI
FACILITY NUMBER: 384004432
VISIT DATE: 06/14/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a 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 publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: www.ada.gov/childqanda.htm.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensees were 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 reviewed AB 1207 with the Licensees. As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. Effective July 1, 2020, Licensees must have proof of completion of EMSA certified lead poison training if applying for a change of location or capacity change to an existing license.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

The Licensee will send the following documents to San Bruno Child Care Office for the file:
  • Control of Property (Rental/Lease Agreement
  • updated LIC 508
  • An updated Facility roster LIC 9040

Licensee Chen, XiaoLi read and signed the report. During today's inspection, no deficiencies were observed. Today's report and site visit notice will be emailed to Chen, XiaoLi by the end of business on 6/14/2022. A receipt confirmation is necessary, and a site visit notification must be posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Brendon Van
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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