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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005001
Report Date: 06/23/2023
Date Signed: 06/23/2023 03:47:52 PM

Document Has Been Signed on 06/23/2023 03:47 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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GONG, QIAN MINFACILITY NUMBER:
414005001
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/23/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Qian Min "Kitty" GongTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Marie Rodriguez conducted a scheduled pre-licensing inspection and met with Applicant Qian Min "Kitty" Gong. Home is a single story house with three bedrooms and two bathrooms that the Applicant owns. Residing in the home is the Applicant, her husband, her mother, and her two minor children. Hours of operation is Monday to Friday from 8:00am to 5:00pm.

LPA and Applicant inspected entire home for health and safety hazards. Daycare Areas: Living room, bedroom # 2 (infant napping room), bathroom #1, and front yard. Off Limit Areas: Kitchen, dining room, bedroom #1, bedroom #3, bathroom #2, back yard, and garage. All off limit areas, including all closets, are properly barricaded. Home is clean and orderly with sufficient lighting and ventilation. Home has age appropriate toys and equipment available for children in care. Home has working smoke and carbon monoxide detectors, a working telephone, and a fully charged fire extinguisher. First aid kit is fully stocked and accessible. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. Applicant has a dog who is licensed and vaccinated. There are no bodies of water on the premises. Per Applicant, there are no firearms in the home.

Applicant states she will conduct an emergency drill at least once every six months and will log drills. Applicant states discipline policy is redirection. Applicant's pediatric first aid/CPR certificate expires June 2025. Postings will be posted by the entrance of the home. Applicant was informed of NO walkers, exersaucers, jumpers, bouncers, and any similar items to be used for children in care and shall be made inaccessible.

Capacity limits of a small and large license were discussed with the Applicant. Applicant was informed that when operating at a large capacity, there must be a helper present.

Small Family Child Care License has been granted and is effective as of today, June 23, 2023.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/23/2023
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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GONG, QIAN MIN
FACILITY NUMBER: 414005001
VISIT DATE: 06/23/2023
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Applicant was reminded about Mandated Reporter training available on CCLD website. Training must be completed every two years for Applicant and staff. Training can be taken online at www.mandatedreporterca.com.

Applicant was reminded, as of September 1, 2016, all staff and volunteers must provide proof of immunization against pertussis (dTap), measles (MMR), and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.662.

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Applicant and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Applicant 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 purchaged 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: http://www.ada.gov/childqanda.htm.

LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
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 CHILD CARE, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: GONG, QIAN MIN
FACILITY NUMBER: 414005001
VISIT DATE: 06/23/2023
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilties, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with Applicant Qian Min Gong.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023
LIC809 (FAS) - (06/04)
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