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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004481
Report Date: 06/15/2022
Date Signed: 06/15/2022 05:05:17 PM

Document Has Been Signed on 06/15/2022 05:05 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:YAN, JESSICA P.FACILITY NUMBER:
414004481
ADMINISTRATOR:YAN, JESSICA P.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 218-9806
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
06/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Jessica YanTIME COMPLETED:
05:10 PM
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On 6/15/2022 at 2:05PM., Licensing Program Analyst (LPA), Luis J. Gomez met with Licensee, Jessica Yan. Purpose of the inspection was explained and was for an unannounced; Annual Random inspection. Present in facility was the licensee and helper caring for nine children (three infant age, six preschool age). Licensee’s home is a three bedroom, two bathroom, two level house. All adults have their criminal record clearance on file. Days and hours of operation are Mon- Fri, 7:30- 5:30pm. Daycare areas are: 1st Floor: Living Room (playroom), Bathroom #1, Napping Area (Dining Room), Family Room and Backyard. Off Limit areas are: 1st Floor: Kitchen, Garage, Laundry Room and Entire 2nd Floor: Bedroom #1, Bedroom #2, Bedroom #3, Bathroom #2, and Bathroom #3. LPA inspected entire home, inside and outside, with licensee for health and safety hazards.

At 2:15PM., the following was observed: home was clean, orderly, and with age appropriate playthings available for the children. Furniture inspected was in good repair. Family room had child size table with chairs for snack and activities. Individual cubbies were located under facility staircase. For napping services, cots and cribs were available. Licensee had one crib for each infant in care; each crib had tight fitting sheet. Bathroom #1, located next family room, was clean with adequate supplies for hand washing. Bathroom fixtures were in operating condition. Off-limit areas had been made inaccessible with child safety gates.

At 2:20PM., Based on observations, LPA confirmed mattress sheet hanging off side of infant crib. Advisory Note: Technical Assistance (LIC9102TA) was issued. Outlets and trash bins had been covered. Detergents, cleaning compounds, wipes, spray bottles, and other items which could pose a danger, were stored inaccessible to children.

At 2:30PM., Based on observations, LPA confirmed infant rocking chair located in family room. Advisory Note: Technical Assistance (LIC9102TA) was issued. Facility was the proper temperature, with adequate ventilation, and lighting. Home had functioning telephone, smoke/ carbon monoxide detector combo and one, fully charged, fire extinguishers (2A:10BC). (REFER TO 809C FOR CONT.)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: YAN, JESSICA P.
FACILITY NUMBER: 414004481
VISIT DATE: 06/15/2022
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(Page 2)
At 2:35P.M, LPA inspected the outdoor play area. Outdoor area was completely enclosed. All playthings inspected where in good repair. Outdoor area had shading for the children. Home does not have any swimming pools, spas, hot tubs, fishponds or other bodies of water.

At 3:00PM., LPA reviewed the facility and children’s records. Personnel records were reviewed and included staff's: Proof required Immunization; (LIC9052) Employee Rights; and (LIC9108) Statement to Report Suspected Child Abuse.

Children's records were reviewed and included the (LIC700) Identification of Emergency Information; (LIC627) Consent for Medical Treatment; (LIC702) Health History; Immunization Record; and (LIC995) Notification of Parent’s Rights. Signed 'Individual Infant Sleeping Plans', (LIC9227) were in children’s files for qualifying infants.

LPA reminded licensee to maintain napping logs, documenting each 15 minute check, for all infants in care.

LPA reminded licensee to renew the mandated reporter training certification. Licensee’s Cardiopulmonary Resuscitation (CPR)/ First Aid Certification was current, expiring on 4/2023.

Licensee is conducting emergency disaster drills every six months; with last drill completed on 5/11/2022, properly logged.

LPA observed required posting, including: Facility License, Notification of Parent’s Rights and Emergency Disaster Plan (LIC610A) properly posted in facility. Children's Roster (LIC500) was reviewed during inspection. Per licensee, isolation of an ill children is in living room.

Per licensees, facility provides all lunch and snack for children in care. LPA asked licensee to ensure all children’s food containers brought to facility by families are properly labelled. Per licensee, home does not have any no guns or weapons. (REFER TO 809C, FOR CONT.)

SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: YAN, JESSICA P.
FACILITY NUMBER: 414004481
VISIT DATE: 06/15/2022
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Licensee was reminded that all adults 18 years and over, living or working in the home, including employee and volunteers, must obtain criminal 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 up to $500.00 maximum per day/ per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep Web page at:https://www.cdss.ca.gov/inforesource/child-care-licesning/public-information-and-resources/safe-sleep as an additional resource. LPA informed licensee of the importance of checking for recalled infant devices on United States consumer Product Safety Commission (CPSC) website at http://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

To improve the quality and value of the new inspection process, a survey will 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 tool, please send them 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/inforesource/community-care-licensing/inspection-process.

Based on today's inspection, no deficiencies were observed in areas evaluated, according to California Title 22, Health and Safety Code of Regulations. Exit interview was conducted with Licensee, Jessica Yan, and signature of this form acknowledges receipt of these documents.



Notice of Site Visit was provided and must be posted for 30 days.

This report must be available in the facility for public review. Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2022
LIC809 (FAS) - (06/04)
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