414005001-6-11-2024-05-CC-JGIL-D65PRZ-20240611113333

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414005001
Report Date: 06/11/2024
Date Signed: 06/11/2024 11:33:44 AM

Document Has Been Signed on 06/11/2024 11:33 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:	GONG, QIAN MIN		FACILITY NUMBER:	414005001
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 8	CENSUS: 2	DATE:	06/11/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:40 AM
MET WITH:	Zhihua Gong		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 6/11/2024, at approximately 8:40 AM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced Case Management/Annual- Licensee Initiated inspection. LPA met with Licensee's father/assistant (A1), and explained the purpose for the inspection. On 03/15/2024 the licensee applied for a Large Family Child Care Home (FCCH). The licensee has been licensed since 06/23/2023 and therefore will have at least one year of experience to apply for a large Family Child Care Home by 06/23/2024. LPA spoke with licensee Qian Min Gong on the phone at about 9:00 AM. Per licensee, a fire clearance has been granted on by the San Mateo Fire Department in March. Licensee also stated she is not home due to her being in a dentist appointment. LPA informed her department has not received clearance forms, and to contact the fire department. Present during today's inspection were licensee's father(A1), licensee's mother and two infant children in care. One infant was the licensee's daughter.

Licensee lives in a single-level home with her souse, father, mother, and two minor children. All adults living in the home have fingerprint clearance on file. The hours of operation are Monday through Friday 9:00 AM to 6:00 PM. The home consists of 3 bedrooms, 2 bathrooms, living/playroom, kitchen/dining area, back yard, front yard and garage.

Day Care Areas: Living room, Bathroom #1, Bedroom #2, Front Yard

Off-limit areas: Bedroom #1 and #3, Bathroom #2, Kitchen, Garage, and backyard

LPA toured day care areas of home with A1. LPA observed the home to be in repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in working condition. LPA observed a fully stocked accessible first aid kit in kitchen area. LPA did not observe any accessible cleaning supplies, poisons, and solutions in day care areas. Home is equipped with one fully charged fire extinguisher and one carbon monoxide detector in main day care area. The licensee also has a fire alarm by the front entrance. LPA observed all electrical outlets in Day Care areas to be properly covered by outlet covers. Facility does not have any children enrolled with allergies and medications. Facility provides all food for the children in her care.

Bathroom for children's use was observed to be in proper working condition. LPA observed bathroom to include appropriate toileting equipment and sanitation products. LPA did not observe any hazardous materials to be accessible to children in the bathroom.

Continue on Page 2...

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

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 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: GONG, QIAN MIN	FACILITY NUMBER: 414005001
	VISIT DATE: 06/11/2024

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

Continued, Page 2...

There is a working phone in the home. The licensee owns the home. LPA observed licensee to utilize playpens for her infants in care. The entire front yard is fully enclosed. The outdoor area is equipped with a variety of toys and materials. LPA did not observe pools, spas or bodies of water.

LPA reviewed one child's records which was complete. Children’s file had record of emergency identification information and consent forms for emergency medical treatment. Licensee let LPA know that C2 was her own child. LPA reminded Licensee to have all proper documentation for the children in care in their files and available for review by the department, including identification forms for her own child. LPA reviewed staff records for licensee which were incomplete. A1 does not have CPR/First Aid available for review or Mandated Reporter training certification. A1 also does not have IR on file. Two Type B deficiencies is being issued on this day in accordance with the California Code of Regulations, Title 22, see LIC 809D. Per licensee, she is not home but can send all missing staff documentation when she returns from personal appointment via email. Licensee has valid CPR/First Aid that expires on 6/2025 and Mandated Reporter Training that expires on 5/2025.

Licensee has licensing documentation properly posted and available for review. The licensee also maintains a childcare roster that was made available for review. Emergency disaster drills are conducted at least once every six months. Drills are not being documented. LPA reminded licensee to document drills and have them available for the department. Per licensee, there are no weapons or firearms in the home.

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.

Continue on Page 3...

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

Page: 2 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: GONG, QIAN MIN	FACILITY NUMBER: 414005001
	VISIT DATE: 06/11/2024

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

Continued, Page 3...

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 childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Licensee was informed that upon receipt of Licensing Management's approval, a license for a Large Family Child Care Home will not be granted and issued to Licensee, Qian Min Gong until fire clearance forms are received by the department, Mandated Reporter/CPR Certification for A1 is completed, and A1 immunization records are submitted to LPA . Once needed documentation from 6/11 visit are made and sent to department a Large Family Child Care License can be issued.

During the exit interview, the licensee, Qian Min Gong and A1, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Two Type B deficiencies are being issued on this day in accordance with the California Code of Regulations, Title 22, see LIC 809D.

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

Exit interview conducted and report was reviewed with the licensee, Qian Min Gong, via phone call. Report was reviewed and signed by A1.

SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 06/11/2024 11:33 AM - It Cannot Be Edited

Created By: Janet Gil On 06/11/2024 at 11:02 AM

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: GONG, QIAN MIN	FACILITY NUMBER: 414005001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in not have Immunization Records avalible for A1 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee plans to send all missing staff documentation to LPA Gil when she has access to personal computer.

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in leaving home with A1 in charge of FCCH with no CPR/First Aid Certification which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/25/2024
	Plan of Correction
1 2 3 4	Licensee plans to regisiter A1 for CPR certification course and submit proof to the department.

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:

Garfield Leung

LICENSING EVALUATOR NAME:

Janet Gil

LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4