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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384004537
Report Date: 07/26/2023
Date Signed: 07/26/2023 04:28:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/24/2023 and conducted by Evaluator Jennifer Yee
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20230724142215
FACILITY NAME:XIE, XIAO HONGFACILITY NUMBER:
384004537
ADMINISTRATOR:XIE, XIAO HONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 706-8707
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 5DATE:
07/26/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Xiao Hong XieTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Licensee did not report to CCL of changes made to the home
INVESTIGATION FINDINGS:
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Licensing Program Analyst, LPA Yee met with the Licensee, Xiao Hong, the helper and 5 children today. The purpose of the visit was explained. LPA Yee inspected the facility. The home is being remodeled. The licensee said she is not aware that she needs to notify the licensing department.

Based on the Department's investigation, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, (Title 22, Div 12 Chp3), are being cited on the attached LIC9099d. See next page for Type B citation. This report has been explained to the licensee.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 05-CC-20230724142215
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: XIE, XIAO HONG
FACILITY NUMBER: 384004537
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2023
Section Cited
CCR
102416.2(a)(2)
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102416.2(a)(2): Reporting Requirements:
Any change in household composition including adults moving in or out of the home and anyone living in the home who reaches his or her 18th birthday.
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The licensee said she did not know she needs to inform CCL because she ensures the remodeling of the house has no interruption to the daycare areas. In the future, she will report to CCL.
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 This requirement was not met as evidence-based upon today's inspection, the licensee failed to report to CCL. This poses a potential health risk to children in care.
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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.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3