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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002549
Report Date: 07/12/2024
Date Signed: 07/12/2024 01:41:59 PM

Document Has Been Signed on 07/12/2024 01:41 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:XU, JUNFACILITY NUMBER:
414002549
ADMINISTRATOR/
DIRECTOR:		XU, JUNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 249-0298
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 10DATE:
07/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Minyi Zhou / Jun XuTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On July 12, 2024 at approximately 8:55am, Licensing Program Analyst (LPA) Tso (certified bilingual Chinese - Mandarin) conducted an unannounced, annual visit to the Family Child Care Home listed above in Mandarin. The LPA was granted entry by the helper, Yimin Zhou (the licensee of another facility (License # 414004959). LPA explained the purpose of the visit. The helper stated that the licensee, Jun Xu was on upstairs to take stuffs. The licensee entered the facility at 9.05am. Present during LPA's visit included licensee, a helper and 10 enrolled children (2 infants and 8 preschool age). The license is operating within capacity limits and ratio during LPA's visit.

Only the Licensee lives in the home. The adult living in the home have criminal record clearance on file. The hours of operation are Monday through Friday 8:00am to 5:30pm. The DAY CARE AREAS are Living Room #1 (Playroom), Dining Area, Bathroom #1, Bedroom #1, Patio Area (side yard) and kitchen. The OFF LIMIT AREAS are rest of the home. Off-limit areas are properly barricaded with child safety gates and/or closed doors. The side yard that was observed to have doors closed at the living room and the bedroom for children in care napping.

The LPA and the licensee both performed inspection of the daycare facility to look for any potential health and safety hazards. Toys and equipment that are suitable for children of the proper age range are provided at the daycare. The building has sufficient lighting and ventilation, and it is free of any defects or conditions that put children at risk. The facility is equipped with a first aid kit that is completely loaded with everything that is required for the treatment of injuries. The daycare facility is equipped with a smoke detector, a carbon monoxide detector, and a fire extinguisher that is always ready for use. Every garbage can and power outlet has been covered. Products for cleaning and washing, detergents, and any other materials that could put children in danger are stored out of the children’s reach. The LPA did not find any walkers, bouncers, or other comparable objects during today’s inspection. According to the licensee, there are reportedly no firearms or other weapons on the premises. The LPA found that the facility did not have any bodies of water. There is water fountain with water pond in the apartment complex. Licensee’s apartment has fence around the play area. (Continue Report on Page 2...)
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE: DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/12/2024
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 7
Document Has Been Signed on 07/12/2024 01:41 PM - It Cannot Be Edited


Created By: Man Tso On 07/12/2024 at 12:00 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: XU, JUN
FACILITY NUMBER: 414002549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, and record review, the licensee did not comply with the section cited above in that LPA observed the emergency drill record which showed last emergency drill was conducted on 12/15/23. Per the helper, an emergency drill was conducted in 6/2024 but did not remember the exact day which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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The licensee shoud conduct an emergancy drill and email to the drill record to the Licensing office by the POC due date (7/26/2024).

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:Garfield Leung
LICENSING EVALUATOR NAME:Man Tso
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 07/12/2024 01:41 PM - It Cannot Be Edited


Created By: Man Tso On 07/12/2024 at 12:00 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: XU, JUN
FACILITY NUMBER: 414002549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

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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Based on interview and record review, the licensee did not comply with the section cited above in that LPA was informed that supervision of infants napping conducted, but no records of infant sleeping checking recorded, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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The licensee shoud perform the 15 minutes sleeping check, record, and email the records to the Licensing Office by the POC due date, 7/26/2024.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in that the Licensee stated did not maintain the valid Pediatric First Aid/CPR certificate. No valid Pediatric First Aid/CPR certificate was provided to LPA for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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The licensee should attend the Pediatric First Aid/CPR training and email the vaid certificate to the Licensing Office by the POC due date, 7/26/2024.
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:Garfield Leung
LICENSING EVALUATOR NAME:Man Tso
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 07/12/2024 01:41 PM - It Cannot Be Edited


Created By: Man Tso On 07/12/2024 at 12:00 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: XU, JUN
FACILITY NUMBER: 414002549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that LPA asked the licensee and helper to provide the records of the helpers for review. However, LPA was told all records were kept by the boss, Catherine. No personal records was provided at the facility for review upon LPA request, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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The Licensee should email all required personnel records to the Licensing Office for review by 7/26/2024.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in tha no files or records of the children in care was provided at the facility for LPA to review upon request, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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The Licensee should email all required children records to the Licensing Office for review by 7/26/2024.
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:Garfield Leung
LICENSING EVALUATOR NAME:Man Tso
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 07/12/2024 01:41 PM - It Cannot Be Edited


Created By: Man Tso On 07/12/2024 at 12:00 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: XU, JUN
FACILITY NUMBER: 414002549

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2024

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
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Based on observation, interview and record review, the licensee did not comply with the section cited above in that the helper could only show the excel digital copy of the Facility Roster via the helper’s cellphone in which missing the fields of dates enrolment and left, instead of the printout upon LPA request for review, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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The lciensee should prepare the updated with all fields and inforamtion required, and keep a copy at the facility. Then email the facility roster by the POC due date, 7/26/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Garfield Leung
LICENSING EVALUATOR NAME:Man Tso
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024


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: XU, JUN
FACILITY NUMBER: 414002549
VISIT DATE: 07/12/2024
NARRATIVE
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(Continued, Page 2...)
The LPA observed that the facility had posted the required forms, including the facility license, Notification of Parental Rights, and Notification of Personal Rights, except Earthquake Preparedness Checklist. The Licensee was reminded to post back the Earthquake Preparedness Checklist. The licensee could only show the excel digital copy of the Facility Roster via then helper’s cellphone in which missing the fields of dates enrolment and left, instead of the printout upon LPA request for review. (Please refer to LIC 809D for citation) The Licensee is aware that smoking is not permitted in a family childcare facility.

Bathroom for children's use was observed to be in proper working condition. LPA did not observe any hazardous materials to be accessible to children. Entire side yard is fully enclosed and fenced. The outdoor area is equipped with a variety of toys and materials. There is a play structure in the backyard that was observed to be in good condition. Flooring in backyard includes artificial grass that was observed to be clean.
LPA asked the licensee to provide the records of the facility, the licensee, the helpers, and the children in care for review. However, LPA was told all records were kept by the boss, Catherine. No files and records of the above mentioned was provided at the facility upon LPA request for review. (Please refer to LIC 809D for citations). LPA asked to licensee and the helper to provide the 15 minutes sleeping check log for the 2 infants in care. LPA was informed that supervision of infants conducted, but no records of infant sleeping checking recorded. (Please refer to LIC 809D for citation).

Per the Licensee, the licensee did not maintain the valid Pediatric First Aid/CPR certificate. No valid Pediatric First Aid/CPR certificate was provided to LPA for review. (Please refer to LIC 809D for citation) LPA observed the emergency drill record which showed the last emergency drill was conducted on 12/15/23. Per the helper, an emergency drill was conducted in 6/2024 but did not remember the exact day. LPA reminded the licensee to conduct emergency drill on every six month and record the drill. (Please refer to LIC 809D for citation).

LPA reminded licensee about Mandated Reporter training available www.mandatedreporterca.com. Licensee was reminded Mandated Reporter training must be renewed every 2 years and all staff whom directly work with children must complete training.

Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622. (Continue Report on Page 3...)
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: XU, JUN
FACILITY NUMBER: 414002549
VISIT DATE: 07/12/2024
NARRATIVE
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(Continued, Page 3...)
To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the 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.

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 22-02-CCP. 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/.

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.

During the exit interview, the licensee, Jun Xu, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Please refer to LIC 809D for today’s citation. A copy of today’s report and the facility’s appeal rights were discussed and given to the licensee. The Notice of Site Visit was given to the licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with the licensee, Jun Xu.

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024
LIC809 (FAS) - (06/04)
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