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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004537
Report Date: 01/09/2023
Date Signed: 01/09/2023 03:25:12 PM

Document Has Been Signed on 01/09/2023 03:25 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:XIE, XIAO HONGFACILITY NUMBER:
384004537
ADMINISTRATOR:XIE, XIAO HONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 706-8707
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
01/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Xiao Hong XieTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA) Yee conducted an annual required inspection today. The purpose of the inspection was explained. LPA and Licensee toured the daycare areas. This is single family home. The licensee owns this home. Present at the facility are licensee, Xiao Hong, 2 helpers and 11 children (3 infants). The facility personnel summary report was reviewed with Xiao Hong and she said it is current. All adults living or working in the home have criminal background check on file. Licensee provides day care from Monday to Friday between 8:00 AM to 6:00 PM.

LPA inspected the day care areas with the licensee. Day Care Areas (lower level): One large room, Son's bedroom, bathroom and backyard. The remaining areas are off limit. There's no pool, spa or any other body of water in the house. Cleaning supplies, poisons and other chemicals are stored out of reach children. The house is in good repair and free of hazards with proper temperature and ventilation. There is carbon monoxide detector, smoke detector, fully charged fire extinguisher and working telephone available in the house. The fire clearance for large FCCH is on file. There is a variety of age appropriate toys in the house.

LPA reviewed the children's record and in ordered. LPA reviewed the staff members and in order. Licensee's CPR, 1st aid card is current until 08-21-2023. The last fire drills and emergency drills were conducted on 08-01-22. A log sheet was reviewed during the visit.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2023
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: XIE, XIAO HONG
FACILITY NUMBER: 384004537
VISIT DATE: 01/09/2023
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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 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. A blank sheet of infant sleep chart was provided.

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.

Notice of Site Visit posted and shall remain posted for 30 days.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2023
LIC809 (FAS) - (06/04)
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