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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004607
Report Date: 10/19/2023
Date Signed: 10/19/2023 01:14:26 PM

Document Has Been Signed on 10/19/2023 01:14 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:CHEN, HELEN Y.FACILITY NUMBER:
384004607
ADMINISTRATOR:CHEN, HELEN Y.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 385-9552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
10/19/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Helen Y. ChenTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst, LPA Yee conducted a follow up inspection today. The purpose of the visit is to clear some of the citations cited on 09/18/23. The licensee, Helen Chen is not at the facility upon arrival. The helper answered the door and called the licensee, Helen. Helen arrived at the facility in 15 minutes. Helen and LPA walked inside the facility together. The inspection authority regulations was discussed again with Helen Chen. "Title 22, Div 12, Chp 1: 102391 Inspection Authority of the Department: Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, the regulations adopted by the Department governing family child care homes, and in accordance with Section 102396". Ms. Chen said she understands.

During today's visit the following deficiency has been corrected.

102425(j)(2): Infant safe sleep log has been corrected.
102417(g)(8): Roster
However, the facility still needs to submit staff immunization.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 3
Document Has Been Signed on 10/19/2023 01:14 PM - It Cannot Be Edited


Created By: Jennifer Yee On 10/19/2023 at 12:04 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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/19/2023
Section Cited
CCR
102370(d)

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102370(d): (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:
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The licensee submitted LIC9182 with photo ID during today's visit. The deficiency is corrected today.
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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.
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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: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2023 01:14 PM - It Cannot Be Edited


Created By: Jennifer Yee On 10/19/2023 at 12:17 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: 10/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
102416.1(a)

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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:
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The facility needs to submit the document by due date, 11/02/2023. Failure to do so will result civil penalty.
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No staff files. The facility needs lic9052, immunication, tb, flu on file. S1, S2 need immunization 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.
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Type B
10/19/2023
Section Cited
CCR102417(g)(8)

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102417(g)(8): operation FCCH:(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:
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The licensee created the roster during the visit. The deficiency is corrected.
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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.
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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: 10/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2023


LIC809 (FAS) - (06/04)
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