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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004483
Report Date: 10/26/2023
Date Signed: 10/26/2023 12:06:48 PM

Document Has Been Signed on 10/26/2023 12:06 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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LI, SUSANNA YANNAFACILITY NUMBER:
384004483
ADMINISTRATOR:LI, SUSANNA YANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 218-0633
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 8DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Susanna Yanna LiTIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yee conducted an Unannounced Required - 1 Year inspection today. The purpose of the visit was explained. Present at the facility are licensee, Susanna, two staff members and 08 children (4 infants). Total children enrolled are 09. The facility personnel summary report was reviewed with Susanna. One staff is not associated to this facility. The licensee filled out the form in front of LPA and associate the staff to the facility during the visit. Current residents are the licensee, Susanna, and one tenant.

Daycare areas are: living room, dining room, bathroom and backyard. The remaining areas of the house are off-limits. The gate leading to upper level is properly barricaded with child safety gates. The licensee, has current CPR, 1ST AID which expires 04/26/2025.

LPA observed the home is clean orderly and properly ventilated. Fire extinguisher is size 2A10BC. Smoke detectors and carbon monoxide is available. There are no bodies of water such as swimming pool or hot tub 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 locks in place making all sharp objects or toxic house hold items inaccessible to children. First aid supplies are available for children. Disciplinary policy was discussed with Licensee today. Home has age appropriate toys and equipment available for the children in care. The facility provides meals. The last fire drills was conducted on 9/20/23.

The children files and staff files were reviewed. Some of the children files were not in order. LPA advised the licensee to keep the forms in order. She said she understands.

During the visit, LPA observed a 4 months old infant napping inside the play pen, off limit areas with blanket on top. After LPA pointed it out the licensee moved the infant to a licensed areas.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LI, SUSANNA YANNA
FACILITY NUMBER: 384004483
VISIT DATE: 10/26/2023
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and
volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with the licensee and discussed the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed 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. LPA is unsure if the small play pen is the right equipment, LPA advised the licensee to check with CPSC.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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/resources/child-care-centers/.

Licensee, Susanna was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee, Susanna, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Susanna.

Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
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Document Has Been Signed on 11/13/2023 02:56 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/31/2023 10:37 AM


Created By: Jennifer Yee On 10/26/2023 at 10:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LI, SUSANNA YANNA
FACILITY NUMBER: 384004483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA observed a blanket on top of the 4 month old infant. Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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After LPA pointed it out, the licensee remove the blanket.
Type B
Section Cited
CCR
102425(j)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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The four months old infant was napping inside the play pen, off limit areas (upper level) and the infant was out of visual sight from the kitchen. During the inspection LPA mentioned to the licensee many times to attend the children with her staffs, the licensee said she has 2 staffs watching the kids. Both staffs were in the outside yard with 7 kids. The infant was napping inside the crib in off limit areas. Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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After LPA pointed it out, the licensee moved the infant to a licensed areas.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ali Zebila
LICENSING EVALUATOR NAME:Jennifer Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


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Document Has Been Signed on 10/26/2023 12:06 PM - It Cannot Be Edited


Created By: Jennifer Yee On 10/26/2023 at 11:22 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LI, SUSANNA YANNA
FACILITY NUMBER: 384004483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3
Alterations to Existing Buildings or Ground: A 4 months old infant was napping inside the play pen in off limit aras.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2023
Plan of Correction
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After LPA pointed it out, the infant was moved to another play pen in licensed daycare areas.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ali Zebila
LICENSING EVALUATOR NAME:Jennifer Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023


LIC809 (FAS) - (06/04)
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