414005001-2-23-2026-05-CC-JTSE-DRL2ZP-20260223165039

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414005001
Report Date: 02/23/2026
Date Signed: 02/23/2026 04:51:15 PM

Document Has Been Signed on 02/23/2026 04:51 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:	GONG, QIAN MIN		FACILITY NUMBER:	414005001
ADMINISTRATOR/ DIRECTOR:	GONG, QIAN MIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 485-9690
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 5	CENSUS: 4	DATE:	02/23/2026
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Licensee, Qian Min Gong		TIME VISIT/ INSPECTION COMPLETED:	05:05 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 2/23/2026, at approximately 1:15PM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual visit at the facility. LPA met with a helper (H1) and explained the purpose of the visit. Present during the visit was Licensee, H1, 2 infants, and 2 preschool-age children. The facility is operating within staffing and ratio requirements on this day. Licensee, Qian Min Gong, was not present upon LPA’s entry to the facility, and arrived at approximately 2:50PM. Day Care Areas: Living Room, Dining Room, Bathroom #1, Bedroom #2, Front Yard. Off Limit Areas: Bedroom #1 and #3, Bathroom #2, Kitchen, Garage, and Backyard. LPA and Licensee inspected the facility for any health or safety hazards. There is a fireplace in the Living Room that has been barricaded to be inaccessible to children in care. There are heating and ventilation controls available for the comfort and safety of children in care. There is a fully charged 2A10BC fire extinguisher present. LPA observed there to be carbon monoxide and smoke detectors present. Electrical outlets are covered or blocked by furniture when not in use. Off-limits areas are kept inaccessible with childproof gates. LPA observed there to be age-appropriate toys and learning materials present. Furniture is age-appropriate and free of rough or sharp edges. Children nap on mats or in pack-and-plays. Bedding is brought from home and taken back once a week for cleaning. Extra bedding is available at the facility as needed. Per Licensee, the facility provides lunch and AM/PM snacks for children in care. Licensee stated that she adjusts menus for children with food allergies. LPA observed that an allergy list was posted in the Kitchen. Storage of medication was discussed. Continued on Page Two

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: GONG, QIAN MIN	FACILITY NUMBER: 414005001
	VISIT DATE: 02/23/2026

NARRATIVE

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The Front Yard was observed to be free of debris and other loose materials. It is enclosed by a fence that is at least four feet high. There are age-appropriate toys and equipment present. There are no swimming pools or other similar bodies of water present. Licensee stated that there is a firearm in the home. LPA confirmed that the firearm is stored appropriate and is inaccessible to children to care.

LPA reviewed 3 staff files, 5 children’s files, and facility records. Licensee’s Pediatric First Aid/CPR training is current and expires 7/2027. Licensee’s Mandated Reporter training is current and expires 6/2026. Children’s files were observed to contain Emergency Identification and Identification (LIC700) and immunization records. LPA advised that Notification of Parents’ Rights must be kept in each child’s file. A children’s roster was observed to be current and made available for review. The facility last conducted an emergency drill on 1/7/2026. Drills are conducted monthly and are properly documented. Required postings were observed to be posted and accessible for review in the Living Room.

LPA observed that infants were napping in Bedroom #2 with sleep sacks. The door to Bedroom #2 was also observed to be closed. Sleep sacks were removed from infants during the visit. Sleep sacks are considered to be swaddling devices. LPA advised that Licensee may use sleep suits or onesies for sleeping infants. H1 was observed to not have Pediatric First Aid/CPR training while supervising children by themselves. Licensee was at a doctor's appointment. Licensee was informed that deficiencies shall be cited today. Sleep sacks were removed and will be returned to families.

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.

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-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for and removing any 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.
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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

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: GONG, QIAN MIN	FACILITY NUMBER: 414005001
	VISIT DATE: 02/23/2026

NARRATIVE

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This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are 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, the Licensee, Qian Min Gong, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

See LIC809D for deficiency cited and cleared today regarding infant safe sleep and deficiency cited regarding First Aid/CPR training. See LIC9102TV for technical violation issued today regarding infant safe sleep. Appeal rights were provided and explained.

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.

NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/23/2026 04:51 PM - It Cannot Be Edited

Created By: Jonathan Tse On 02/23/2026 at 03:49 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: GONG, QIAN MIN	FACILITY NUMBER: 414005001
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(f)

Infant Safe Sleep

An infant shall not be swaddled while in care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having 2 infants napping with sleep sacks, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/09/2026
	Plan of Correction
1 2 3 4	Sleep sacks were removed during the visit. This deficiency shall be cited and cleared during the visit.

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 observation and record review, the licensee did not comply with the section cited above by having H1 supervising children without having current Pediatric First Aid/CPR training, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/23/2026
	Plan of Correction
1 2 3 4	Licensee shall register H1 for an EMSA approved Pediatric First Aid/CPR training and submit proof of registration to LPA via email.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Ali Zebila
NAME OF LICENSING PROGRAM MANAGER:

	Jonathan Tse
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC809 (FAS) - (06/04)

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