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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004937
Report Date: 08/29/2024
Date Signed: 08/29/2024 02:34:59 PM

Document Has Been Signed on 08/29/2024 02:34 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:GAO, QIUYUFACILITY NUMBER:
414004937
ADMINISTRATOR/
DIRECTOR:		GAO, QIUYUFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(302) 766-0612
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 8DATE:
08/29/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Licensee, Qiuyu GaoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On August 29th, 2024 at approximately 12:05pm, Licensing Program Analyst (LPA) Tapia-Mandujano arrived at the facility to conduct a Case Management-Licensee Initiated inspection. LPA rang door bell and Assitant, Zhenyuan Li opened the door and let LPA through the door. Per assistant, licensee was on her way back from an appointment. LPA explained the purpose of the inspection to Assistant. Present in the home were two assistants supervising 8 children (3 infants and 5 preschool age). All adults living and working at the facility have fingerprint clearance and are associated.

Upon arrival, LPA observed that there was a child in Bedroom #3 sleeping in a pack and play that was being pulled out by Assistant into hallway from the bedroom. Type B citation was issued. LPA also observed that the pack and play where the child was sleeping had a stuff animal and a bottle inside. Type B citation was issued.

At approximately 12:20pm, Licensee arrived from her appointment. LPA explained the purpose of the inspection. Licensee has requested to add Bedroom #3 as part of a Daycare Area and remove Bedroom #2. Updated Fire Inspection was received on 7/30/24 by Menlo Park Fire Department.

LPA inspected Bedroom #3 for health and safety hazards. Bedroom #3 will be used an infant nap room. LPA had licensee remove all the potential hazards and secure the bedroom. After corrections, Bedroom #3 was observed to be clean with proper ventilation and lighting. Electrical outlets were covered, furniture were observed to have corner protectors, closet had a safety lock on both doors, and all potentially hazard items were removed. Pack and Plays were observed to be set up in the bedroom. Bedroom #3 also contains a functioning smoke detector.

LPA reminded licensee of Safe Sleep regulations. LPA reminded licensee since the plan for Bedroom #3 to nap infant children that door to the room must remain open and unobstructed at all times when children are sleeping. LPA also reminded licensee that the placement of the cribs or pack and plays should not hinder the entrance/exit. LPA also reminded licensee all cribs and/or pack and plays must be free of all loose articles and objects.

Continued on Page 2...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: GAO, QIUYU
FACILITY NUMBER: 414004937
VISIT DATE: 08/29/2024
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LPA will recommend Bedroom #3 be added to daycare area, effective 8/29/2024.

NEW DAYCARE AREAS ARE: Living Room, Dining Room, Bathroom #1, Bedroom #3 (sleeping only), and backyard. OFF limit areas: Kitchen, Bedroom #1 and #2, Bathroom #2, Laundry Room (Pass thru only to backyard), Storage shed in backyard, Garage, and front yard/driveway. All off limit areas are properly barricaded.

***California Code of Regulations, (Title 22, Div. 12, Ch 3) were cited on this day.

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

This report must be available in the facility for public review. An exit interview was conducted with licensee, Qiuyu Gao. Appeal Rights were provided.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
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Document Has Been Signed on 08/29/2024 02:34 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 08/29/2024 at 01:52 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: GAO, QIUYU
FACILITY NUMBER: 414004937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
102416.3(a)(6)

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102416.3: Alterations to Existing Buildings or Grounds: (a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
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Licensee will submit written statements where assistants acknowledge that off limit areas cannot be used for children in care.

Written statement will be emailed to LPA Tapia-Mandujano by 9/06/24.
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Based on observation and interview, the licensee did not comply with the section cited above as LPA observed a child that was sleeping in a pack and play being taken out of Bedroom #3, a room that is labeled as an "off limits" area prior to being approved by the department which poses a potential health, safety or personal rights risk to persons in care.
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LPA will clear deficiency as of today, since Bedroom #3 has been approved during today's inspection.
Type B
09/06/2024
Section Cited
CCR102425(b)

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102425:Infant Sade Sleep: (b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidence by :
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Stuff animal and bottle were removed upon LPA requesting to remove those items out of the pack and play.

Licensee will give a training to assistants about safe sleep regulations that must be followed.
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Based on observations, LPA observed an infant child sleeping in a pack and play with a stuff animal and bottle inside of the pack and play which poses a potential health, safety or personal rights risk to persons in care.
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Licensee will submit written statements where assistants acknowledge that they are aware of the Safe sleep regulations and agree to follow set regulations.

Written statement will be emailed to LPA Tapia-Mandujano by 9/06/24.
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:Marie Rodriguez
LICENSING EVALUATOR NAME:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024


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