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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004439
Report Date: 05/30/2025
Date Signed: 05/30/2025 04:49:48 PM

Document Has Been Signed on 05/30/2025 04:49 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 QIUFACILITY NUMBER:
414004439
ADMINISTRATOR/
DIRECTOR:		LI, JIN QIUFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 245-7979
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 4DATE:
05/30/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:38 PM
MET WITH:Jin Qiu LiTIME VISIT/
INSPECTION COMPLETED:
05:00 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 May 30, 2025, at approximately 1:30 p.m., Licensing Program Analyst (LPA) Zeynep Basak conducted an unannounced annual inspection, met the licensee, Jin Qiu Li, and explained the purpose of the inspection.
LPA observed the licensee and four children (1 infant, 1 toddler, 2 preschoolers) were present. The licensee complies with the licensing capacity during the time of inspection. The children’s roster had been reviewed and was found to be complete and up to date.

The licensee rents 3 bedroom, two bathroom house and she stated that four people live at home. LPA observed one of the individual (daughter in law) does not have fingerprint clearance through the Guardian website. According to the licensee, she came to country with a green card recently. Jin Qiu provided a notary fingerprint clearance proof that the individual obtained during Green Card process to the LPA. LPA discussed it with the licensee and Jin Qiu stated daughter in law will obtain a backgraound clearance through the Guardian during the weekend and provide a proof to the LPA via email by Monday, 6/2/2025.
The Child Care Home operates from Monday through Friday, from 8:00 a.m. to 6:00 p.m.

Childcare areas: Living room, Kitchen, Bedroom #2, Bathroom #1, and backyard.
The off-limit areas: Bedroom #1, bedroom #3, bathroom #2, and garage. Off-limit areas are properly barricaded with child safety locks and/or closed doors.
According to the licensee, there have been no changes to the previously approved childcare areas and off-limits areas. LPA observed all off-limits areas to be securely barricaded and inaccessible to children in care.
See page 2.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Zeynep Basak
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
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: 05/30/2025
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
Page 2.
LPA observed the childcare home to have a functioning telephone and verified contact information. The licensee stated that there is a a gun in the home, LPA observed it in a container with firing pins and it was unlocked. A Technical Violation will be issued today. The licensee stated they will place them separately in a lock drawer or cabinet and provide a proof to the LPA via email by Monday, 6/2/2025.

The licensee stated that breakfast, lunch, and snacks are provided for children in addition to drinking water.

LPA and the licensee inspected the childcare areas for health and safety hazards. LPA observed the daycare area to be clean, with all outlets covered. LPA observed that all cleaning supplies and chemicals were properly stored and inaccessible to children. LPA observed the daycare area to be equipped with age-appropriate furniture, toys, books, and educational materials.

LPA observed mat and 2 cribs in the childcare and the licensee verified that children bring their own sheets and blankets from home. LPA observed a sleep sack in the crib, and discussed it with the licensee. Jin Qiu removed the sleep sack during the inspection. LPA observed 15-minute sleep check log not maintained. A Technical Violation will be issued. The licensee acknowledged that no baby walkers, bouncers, or similar items are used during daycare hours.

LPA inspected the children’s bathroom and observed it to be clean and sanitary, with no chemicals within the children’s reach.LPA confirmed with the licensee that an isolation area is available at the corner in the living room for ill children while waiting for their guardians to arrive. The licensee confirmed that no children currently have allergies or require medication.

LPA reviewed 6 children’s files and found that all required records were in the file, including Emergency Cards and Parental Rights forms. LPA reviewed the staff file and found that the licensee's Mandated Reporter training certificate expired in October, 2024. A Technical Violation will be issued today.
The licensee stated she will renew it in 3 weeks and provide a proof to the LPA on 6/20/25 via email. The licensee has a valid CPR and First Aid certification expire in December 2025.

See page 3.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Zeynep Basak
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 05/30/2025
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
Page 3.
Per the licensee, emergency drills are conducted at least once every six months, and the latest drill was conducted on March 17, 2025.

LPA observed that all required forms and postings were displayed in the Child Care Home, including the License and Parent’s Rights Poster.

Per the licensee, the facility carries liability insurance for the daycare.

The licensee was reminded that all adults 18 years of age or older living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption as specified in Health and Safety Code Section 1596.871. This must occur prior to initial presence in a licensed Family Child Care Home. LPA informed the licensee that a civil penalty of $100 per person per day will be assessed for unqualified adults present for a maximum of five days. If this is a repeat violation, the penalty may increase to $500 per person per day after the fifth day.

LPA discussed the safe sleep regulations with the licensee and shared the Child Care Licensing Safe Sleep webpage located at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the licensee about the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov. LPA recommended that the licensee register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed with the licensee. For additional information, LPA referred the licensee to PIN 22-02-CCP. LPA informed the licensee that when any IMS is provided, a Plan for Providing IMS must be submitted to the Department. Information regarding ADA compliance was also shared, including the toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY). A publication titled “Commonly Asked Questions about Child Care Centers and the ADA” is available at https://www.ada.gov/resources/child-care-centers/.

See page 4.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Zeynep Basak
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 05/30/2025
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
Page 4.
LPA also provided information about the MyChildCarePlan.org website, a consumer education resource that connects families with child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the inspection process, LPA informed the licensee that a survey may be sent to the email address on file. The licensee was encouraged to complete the survey and share her inspection experience. For additional information regarding the inspection process, the licensee was referred to the program website at https://www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

During the inspection, the licensee confirmed that there are no registered sex offenders living in the facility. LPA completed the RSO profile in FAS.


Three Technical Violations will be issued today.

The exit interview was conducted, and the report was reviewed with the licensee, Jin Qiu Li.

A notice of site visit was provided to be posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Daniel J Oquendo
NAME OF LICENSING PROGRAM ANALYST: Zeynep Basak
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5