414004947-11-28-2023-05-CC-JTSE-CXZQGS-20231128111002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004947
Report Date: 11/28/2023
Date Signed: 11/28/2023 11:10:25 AM

Document Has Been Signed on 11/28/2023 11:10 AM - 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:	LOI, ANGELLA		FACILITY NUMBER:	414004947
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 4	DATE:	11/28/2023
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Licensee, Angella Loi		TIME COMPLETED:	11:25 AM

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 11/28/2023, at approximately 8:40AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual and case management visit at the facility for a capacity increase. LPA was granted entry to the facility by Licensee, Angella Loi. LPA explained the purpose of the visit. Present in the facility were Licensee, Licensee’s husband, two helpers, and four infants. The facility is in compliance with capacity requirements. The home is a one-story, two-bedroom, two-bathroom home. Daycare Areas: Living Room (Room #1), Rear Bedroom (Room #2), Play Room (Room #3), Bathroom #1, Bathroom #2, and Backyard. Off-limits Areas: Front Bedroom, Kitchen (only used as pass-through area into Backyard), ADU (Accessory Dwelling Unit) in Backyard, and Garage. LPA and Licensee inspected the home for any health and safety hazards. The home is kept in clean and orderly condition. Children enter the facility from the side of the home adjacent to the garage, and enter the facility through the Play Room. All required postings were observed to be posted in the Play Room. There are age-appropriate toys and learning materials present. Outlets in the home are covered with childproof covers. LPA observed that was at least one crib present for each infant enrolled at the facility. There are two combination smoke and carbon monoxide detectors present in the daycare area that are operational. There is a fireplace located in the Living Room that is covered by a wooden panel and a foam cover. The home is equipped with a fully charged 3A40BC fire extinguisher. There is a first aid kit that was observed to be fully equipped. Off-limits areas are barricaded and kept off-limits for children in care. Per Licensee, there are no firearms in the home. Continued on Page Two

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

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: LOI, ANGELLA	FACILITY NUMBER: 414004947
	VISIT DATE: 11/28/2023

NARRATIVE

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The backyard was observed to be clean and free of debris. There is a play area in the backyard that has sufficient cushioning in the form of foam pads for children to play on. The equipment and play materials present in the backyard are kept clean and in good repair. There is an ADU present in the yard that is kept off-limits and locked. The yard is enclosed by a fence that is at least five feet high.

The facility was granted fire clearance by San Mateo County Consolidated Fire Department on 10/16/2023. There is a fire alarm system present in the home. There are two emergency exit routes, which are posted with the required postings in the Play Room. The first emergency exit route is through the living room and then through the front door of the home. The second emergency exit route is through the backyard and then out through the daycare entrance adjacent to the garage. There are two doors leading to the backyard, one in the Play Room and one in the Kitchen.

LPA reviewed four staff files and four children’s files. All children’s files were observed to be complete, and included immunization records, Identification and Emergency Information, and Notification of Parents’ Rights. Licensee provided infant sleep logs for review during the visit. LPA observed infant sleep logs to meet licensing requirements. Staff files were observed to have all Mandated Reporter Training and First Aid/CPR certificates that are current.

Per Licensee, the last emergency drill was conducted on 6/20/2023. Emergency drills are conducted and logged properly. LPA reminded Licensee of the requirement to conduct emergency drills every six months. The facility prepares breakfast, lunch, and afternoon snack for children in care.

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.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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: LOI, ANGELLA	FACILITY NUMBER: 414004947
	VISIT DATE: 11/28/2023

NARRATIVE

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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, Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA will recommend approval of a Large Family Child Care Home license as of today, November 28, 2023.

No deficiencies were cited during today’s visit. See LIC9102-TV for Technical Violation issued today.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Angella Loi.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC809 (FAS) - (06/04)

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