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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
384004607
Report Date:
09/18/2023
Date Signed:
09/19/2023 10:45:41 AM
Document Has Been Signed on
09/19/2023 10:45 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
SAN BRUNO CHILD CARE
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
CHEN, HELEN Y.
FACILITY NUMBER:
384004607
ADMINISTRATOR:
CHEN, HELEN Y.
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(415) 385-9522
CITY:
SAN FRANCISCO
STATE:
CA
ZIP CODE:
94112
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
12
DATE:
09/18/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:30 PM
MET WITH:
Helen Y. Chen
TIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yee conducted an Unannounced Required - 1 Year inspection today. LPA ring the door bell. The helper opened the inside door twice. LPA introduced herself twice with proper identification and informed the helper the purpose of the visit in English and Chinese. The helper did not let the LPA in. Thirty minutes later the licensee, Helen Chen arrived at the facility. LPA and the licensee enter the facility together. Inspection authority was explained to the licensee, Helen Chen. LPA and the licensee did a walk through of the day care areas. Present at the facility are the licensee, 2 helpers, and 12 children. Total children enrolled are 14. The facility personnel summary report was reviewed with Helen and updated during the visit. Current residents are the licensee, Helen, and her children ages 10 and 7 years old.
Daycare areas are
:
living room, dining room, kitchen, bathroom, family room and backyard.
.
The remaining areas of the house are off limits. The licensee, Helen has current CPR, 1ST AID which expires 04/2025.
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 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 monthly.
The children files and staff file have been reviewed. Children files are incomplete. Staff files are not available.
SUPERVISORS NAME
:
Ali Zebila
LICENSING EVALUATOR NAME
:
Jennifer Yee
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/18/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2023
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
8
Document Has Been Signed on
09/19/2023 10:45 AM
- It Cannot Be Edited
Created By:
Jennifer Yee
On
09/18/2023
at
03:29 PM
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:
CHEN, HELEN Y.
FACILITY NUMBER:
384004607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/18/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
SleepLog was not available. Based on today's inspection and record review, 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:
09/22/2023
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, one staff fingerprint is not assoicate to this facility. 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:
09/22/2023
Plan of Correction
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2
3
4
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:
09/18/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2023
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
09/19/2023 10:45 AM
- It Cannot Be Edited
Created By:
Jennifer Yee
On
09/18/2023
at
03:29 PM
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:
CHEN, HELEN Y.
FACILITY NUMBER:
384004607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/18/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102391(b)
Inspection Authority of the Department
(b) The licensee shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of family child care laws or regulations. The Department shall exercise this authority as specified in Health and Safety Code Section 1596.8535(a).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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LPA introduced herself with proper identification, the helper answered the door twice and did not allow LPA to inspect. Based on today's inspection, 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. Inspection authority regulation was explained to the licensee, Helen Chen. If this occurred again, civil penalty of $500 will be issued.
POC Due Date:
09/18/2023
Plan of Correction
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4
The licensee arrived at the facility 30 mins later and LPA and the licensee entered the facility together. The deficiency has been corrected.
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
No staff files. The facility needs lic9052, immunication, tb, flu on file. Based on record review, 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:
09/29/2023
Plan of Correction
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2
3
4
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:
09/18/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2023
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
09/19/2023 10:45 AM
- It Cannot Be Edited
Created By:
Jennifer Yee
On
09/18/2023
at
03:29 PM
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:
CHEN, HELEN Y.
FACILITY NUMBER:
384004607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/18/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, 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:
09/29/2023
Plan of Correction
1
2
3
4
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, 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:
09/29/2023
Plan of Correction
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2
3
4
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:
09/18/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2023
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
09/19/2023 10:45 AM
- It Cannot Be Edited
Created By:
Jennifer Yee
On
09/18/2023
at
03:29 PM
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:
CHEN, HELEN Y.
FACILITY NUMBER:
384004607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/18/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, 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:
09/29/2023
Plan of Correction
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2
3
4
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, 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:
09/29/2023
Plan of Correction
1
2
3
4
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:
09/18/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2023
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
09/19/2023 10:45 AM
- It Cannot Be Edited
Created By:
Jennifer Yee
On
09/18/2023
at
03:29 PM
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:
CHEN, HELEN Y.
FACILITY NUMBER:
384004607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/18/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, 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:
09/29/2023
Plan of Correction
1
2
3
4
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
09/18/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2023
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
09/19/2023 10:45 AM
- It Cannot Be Edited
Created By:
Jennifer Yee
On
09/18/2023
at
03:29 PM
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:
CHEN, HELEN Y.
FACILITY NUMBER:
384004607
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
09/18/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, 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:
09/29/2023
Plan of Correction
1
2
3
4
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:
09/18/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2023
LIC809
(FAS) - (06/04)
Page:
7
of
8
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:
CHEN, HELEN Y.
FACILITY NUMBER:
384004607
VISIT DATE:
09/18/2023
NARRATIVE
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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, 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.
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 the publication: Commonly Asked Questions about Child Care Centers and the ADA, available at:
http://www.ada.gov/childqanda.htm
Licensee was reminded about Mandated Reporter Training available on the CCLD website
www.ccld.ca.gov
or
www.mandatedreporterca.com
). The licensee completed AB1207 on 6/14/22. However, both helpers need to complete AB1207.
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.
> This report must be available in the facility for public review. Notice of site visit was given and must remain posted for 30 days.
Licensee was advised any additional questions to call Office, M-F, 8 am-5 pm, 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:
09/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2023
LIC809
(FAS) - (06/04)
Page:
8
of
8