414004439-9-5-2024-05-CC-MTSO-D8TQNG-20240905121908

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004439
Report Date: 09/05/2024
Date Signed: 09/05/2024 12:19:19 PM

Document Has Been Signed on 09/05/2024 12:19 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:	LI, JIN QIU		FACILITY NUMBER:	414004439
ADMINISTRATOR/ DIRECTOR:	LI, JIN QIU		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 245-7979
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 7	CENSUS: 5	DATE:	09/05/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:51 AM
MET WITH:	Jin Qiu Li		TIME VISIT/ INSPECTION COMPLETED:	12:35 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 at approximately 8:50am, Licensing Program Analyst (LPA) Tso, certified bilingual – Chinese, Mandarin, conducted an unannounced, annual visit to the Family Child Care Home listed above. The LPA was granted entry by the Licensee, Jin Qiu Li. LPA explained the purpose of the visit. Present during LPA's visit included licensee, licensee's spouse, licensee's adult child, and 5 enrolled children (2 infants and 3 preschool age).The license is operating within capacity limits and ratio during LPA's visit. Licensee lives in the home with their spouse, and an adult child. All adults living in the home have criminal record clearance on file. The hours of operation are Monday through Friday 8:00am to 6:00pm. The DAY CARE AREAS are Living room, kitchen, bedroom #2, bathroom #1, and backyard. The OFF LIMIT AREAS are Bedroom #1, bedroom #3, bathroom #2, and garage. Off-limit areas are properly barricaded with child safety gates and/or closed doors. 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 facility 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, 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. However, LPA observed the low cabinet at the kitchen (barricaded with a gate) with sharp items. The licensee removed the sharp items to the high cabinet inaccessible to children immediately. The LPA did not find any walkers, bouncers, or other comparable objects during today’s inspection. According to the licensee, there are reportedly firearms on the premises. The firearms are locked at the off-limit area. LPA reminded the licensee that the ammunition shall be stored and locked separately from firearms. The LPA found that the facility did not have any bodies of water. (Continued Report on Page 2...)

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
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 4

Document Has Been Signed on 09/05/2024 12:19 PM - It Cannot Be Edited

Created By: Man Tso On 09/05/2024 at 11:25 AM

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: LI, JIN QIU	FACILITY NUMBER: 414004439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)(c)

Infant Safe Sleep

Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in, the licensee stated that no 15 minutes sleeping check record was done, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/19/2024
	Plan of Correction
1 2 3 4	The licensee would do the sleeping checking and record. The records would be sent to the Licensing Office by 9/19/2024.

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:

Garfield Leung

LICENSING EVALUATOR NAME:

Man Tso

LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: LI, JIN QIU	FACILITY NUMBER: 414004439
	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...)
The LPA observed that the facility had posted all the required forms, including the facility license, Notification of Parental Rights, Earthquake Preparedness Checklist, and Notification of Personal Rights. 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 backyard 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 grass that was observed to be clean.

LPA reviewed four children’s records. Children’s files have a record of emergency identification information on file. There was no 15 minutes sleeping check record found. (Refer to LIC809D). Licensee's Pediatric First Aid/CPR is current and will expire 12/2025. Emergency drills are properly logged and maintained. Last emergency drill was conducted on 03/15/2024. Licensee has licensing documentation properly posted and available for review.

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.

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.
(Continue Report on Page 3...)

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
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: 3 of 4

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: LI, JIN QIU	FACILITY NUMBER: 414004439
	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 3...)
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, Jin Qiu Li, confirmed that there are no Registered Sex Offenders living in the facility.

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, Jin Qiu Li.

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Man Tso
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: 4 of 4