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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004801
Report Date: 09/05/2024
Date Signed: 09/05/2024 05:29:51 PM


Document Has Been Signed on 09/05/2024 05:29 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 CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:YE, XINHUAFACILITY NUMBER:
384004801
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
09/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:48 PM
MET WITH:Xinhua YeTIME COMPLETED:
05:40 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
On September 5, 2024, approximately 3.20pm, Licensing Program Analyst (LPA) Tso, certified bilingual Chinese, Cantonese met with the Applicant, Xinhua Ye, for an announced pre-licensing inspection. The visit was conducted in Cantonese. The applicant was present at the home. The applicant owned this 2-story single-family house. The house has 2 bedrooms, 2 baths, a kitchen, and a living room on the upper level; on the lower level is a garage and backyard.

Further to the last pre-licensing visit, LPA followed up the completeness of the items before licensure. The followings were inspected and were observed completed for the licensure.

· applicant must move into the house completely.
· install childproof locks to the windows in the living room and bedroom #1.
· barricade the rails in the foyer.
· mount the bookshelves to the wall in the living room.
· installed a sharp corner protector on the white bookcase in the living.
· install a gate at the entrance between the living and dining rooms.
· install a gate at the entrance of the dining room from the stairway.

However, LPA observed that the CRP and First Aid training certificate was expired in 02/2024.

(Continued on page 2, ...)
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Man TsoTELEPHONE: (650) 379-9021
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: YE, XINHUA
FACILITY NUMBER: 384004801
VISIT DATE: 09/05/2024
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
(Continued, page 2 ...)

Prior to recommended for licensure, application must complete the following for review:
  • Proof of valid CRP and First Aid training certificate(s) issued by EMSA certified provider.

The report was reviewed and signed by the Applicant, Xinhua Ye. Today's report was provided to the Applicant. This report will be kept in the facility file and available for public review upon request. Desk duty is available Monday - Friday, 8:00 a.m. – 5:00 p.m. (650) 266-8800. Website for Forms and Regulations: www.cdss.ca.gov
SUPERVISOR'S NAME: Garfield LeungTELEPHONE: (650) 266-8867
LICENSING EVALUATOR NAME: Man TsoTELEPHONE: (650) 379-9021
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2