<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004607
Report Date: 09/08/2022
Date Signed: 09/08/2022 12:26:37 PM

Document Has Been Signed on 09/08/2022 12:26 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, HELEN Y.FACILITY NUMBER:
384004607
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/08/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Helen ChenTIME COMPLETED:
01:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst, LPA Yee conducted a pre-licensing inspection today. LPA met with the licensee, Helen Chen. This is a change of location previously licensed at Cambon Dr. SF, CA, facility number 384004302. Current residents are Helen Chen and her two children ages 9 year old, 6 year old. The control of the property of is on file. Fire clearance approval for large is on file. Days and hours of operation: Monday to Friday between 7:30 AM to 6:00 PM.

Day Care Areas (level #2): living room, dining room, kitchen, bathroom, family room and backyard. Off-limit areas: level 1, level 3, deck areas on level 2. The home is equipped with a smoke detector, carbon monoxide, and a fire extinguisher size 2A10BC. LPA advised the applicant to conduct emergency drills once every six months and keep a log sheet. The facility does not have pets or bodies of water such as a swimming pool, or hot tub. Discipline policy was discussed. The facility will provide morning snacks, lunches, and afternoon snacks.

The applicant has the required immunization records on file. The 8 hours Health and Safety certificate is on file. CPR and 1st aid are current until 4/17/2023.

LPA review AB 1207 with the Licensee. As of January 1, 2018, all staff members are required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. AB 1207 certificate for the applicant is on file. The Child Abuse Mandated Reporter Training was completed on 6/14/2022.

Incidental Medical Services (IMS) policy was discussed. This facility plans to provide Incidental Medical Services - IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 102417. 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: http://www.ada.gov/childqanda.htm

continue next page.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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, HELEN Y.
FACILITY NUMBER: 384004607
VISIT DATE: 09/08/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, before 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 applicant 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 the applicant 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 reviewed with the applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.
Individual Infant Sleeping Plan (LIC9227) form was provided. Technical support for COVID was discussed. Website for forms and regulations: www.ccld.ca.gov.

Advisory: more rubber cushion under the play structure.


LPA will recommend a large license effective today, 9/8/2022.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2