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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004473
Report Date: 09/03/2021
Date Signed: 09/03/2021 11:43:26 AM

Document Has Been Signed on 09/03/2021 11:43 AM - 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:ZHENG, WEI XIANGFACILITY NUMBER:
384004473
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/03/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Wei Xiang Zheng (Crystal)TIME COMPLETED:
12:00 PM
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On September 03, 2021 at approximately 10:30am, Licensing Program Analyst (LPA) Winnie Ly, conducted a scheduled Relocation Pre-Licensing inspection and met with Licensee Wei Xiang Zheng (Crystal). LPA and licensee inspected the entire home for Health and Safety Hazards. Licensee rents and resides here with her two minor children. Per licensee, her husband will return from the Navy and will reside here with them.

Day Care Areas are two bedrooms, livingroom/dining room, a bathroom and the patio will be used for parents to occasionally drop off and pick up children. Off Limit Areas are kitchen, all walk in closets and a bathroom in the bedroom.

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.


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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2021
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: ZHENG, WEI XIANG
FACILITY NUMBER: 384004473
VISIT DATE: 09/03/2021
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Licensee 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.

Licensee 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

Licensee 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 Licensee. A copy of this report will be emailed to licensee. Licensee has been advised to acknowledge received of reports.

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 Relocation Child Care License is approved and will be effective as of today, 09/03/2021.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
LIC809 (FAS) - (06/04)
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