384004815-1-17-2024-05-CC-YNAR-CZKRSG-20240117121644

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 384004815
Report Date: 01/17/2024
Date Signed: 01/17/2024 12:16:57 PM

Document Has Been Signed on 01/17/2024 12:16 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:	HUANG, XIUWEN		FACILITY NUMBER:	384004815
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	01/17/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Xiuwen Huang & Jenny Kei		TIME COMPLETED:	12:45 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 Analysts (LPAs) Nasiripour and Van conducted an announced Pre-licensing Inspection. LPA met with the licensee, Xiuwen Huang for the inspection. Licensee had a friend, Jenny Kei, attending for assistance for translation. The licensee rents and lives in the 2-bedroom apartment unit with her daughter, who is a minor. The apartment has 2 bedrooms, 1 bathroom, a kitchen, and a storage closet. The off-limit areas are the 2 bedrooms and storage closet. LPAs inspected the entire apartment, including the off-limit areas, for health and safety hazards. The apartment was clean and in order, the temperature and lighting were adequate, and the toxins and harmful items were made inaccessible to the children. The Licensee installed a child-safety gate in the padded “daycare area,” located in the living room, which will prevent access to the windows, which are also equip with two locks on either side. Licensee has a 6’ bookshelf in the daycare area, which is mounted to the wall. Daycare Areas: Living room and kitchen Off-Limit Areas: Master bedroom Guest Bedroom Storage Closet Continued on Page 2..

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Yasha Nasiripour
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HUANG, XIUWEN	FACILITY NUMBER: 384004815
	VISIT DATE: 01/17/2024

NARRATIVE

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The apartment had a fully charged 2A10BC fire extinguisher, working cellular phone, working smoke and carbon monoxide detectors, and first aid supply kit available. LPAs inspected first aid supply kit to confirm all needed supplies. The Licensee covered all the electrical outlets. Licensee was reminded to ensure security of all knives and sharp objects and that they are inaccessible to children. The apartment does not have a fireplace. The Licensee has a diaper-changing table available in the padded daycare area, which is detachable from the infant crib. Licensee reports for infants who require bottle feeding, Licensee will hold infant for feedings. Licensee reports that parents will provide all diapers and wipes, and those items will be stored in each child’s daycare box. License showed LPAs children’s daycare boxes for personal items once enrolled. LPAs communicated to Licensee to detach diaper-changing table from crib whenever there is an infant sleeping in the crib. Licensee showed LPAs nap-mats and tight-fitting sheets for infant crib and toddlers. Daycare is equipped with Infant feeding chair and toddler table for children to eat snacks and lunch. Per Licensee, parents of infants will provide bottles and infant formula, and Licensee will wash and return bottles to parents when they pick their child up at the end of the day. Per the Licensee, they have no guns, weapons, or pets in the apartment. Per the Licensee, she will provide breakfast, lunch, afternoon snack and milk, and dinner to all enrolled children. Licensee reports they will create a monthly menu and provide it to families, in case their children have any food allergies or dietary restrictions. Licensee will also provide drinking water from a filter. The bathroom was clean, in order, had a trash bin with a tight lid, and had locks on every drawer. The lower sink cabinet was also locked.
Licensee does not have required postings available yet.

The following items must be completed before licensure:
Install childproof locks on all drawers in the kitchen.
Install childproof locks on the dishwasher, located in the kitchen.
Install childproof locks on doors to both bedrooms.
Install a childproof lock on the laundry door, located in the bathroom.
Install a childproof lock, childproof door handle, or door charm to the ingress / egress door.
Install corner cushions on dining table, located in kitchen.
Install childproof lock on refrigerator door, located in the kitchen.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Yasha Nasiripour
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HUANG, XIUWEN	FACILITY NUMBER: 384004815
	VISIT DATE: 01/17/2024

NARRATIVE

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Criminal Record Clearance - Licensee was reminded that all adults 18 and over living or working in home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Safe Sleep - 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-andresources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Subscribe to CCLD important information - Child Care Centers and Family Child Care Homes:
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.
To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Yasha Nasiripour
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HUANG, XIUWEN	FACILITY NUMBER: 384004815
	VISIT DATE: 01/17/2024

NARRATIVE

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and select the Child Care option to receive email communication.

MyChildCarePlan.org – Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Megan’s Law - Family Child Care Homes
On this date, 01/17/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Review of records to be maintained - Family Child Care Homes
LPA reviewed with [applicant, licensee, or facility representative] 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. Entrance Checklist was provided to the applicant.

APPLICANT RENTS THE HOME AND HAS LANDLORD CONSENT:
Because the applicant rents the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Exit Interview - Exit interview conducted, and report was reviewed with the Licensee Xiuwen Huang, and friend, Jenny Kei

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Yasha Nasiripour
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024

LIC809 (FAS) - (06/04)

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