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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005016
Report Date: 06/15/2023
Date Signed: 06/15/2023 03:10:22 PM

Document Has Been Signed on 06/15/2023 03:10 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:XU, JIEFACILITY NUMBER:
414005016
ADMINISTRATOR:XU, JIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 338-8177
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/15/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jie XuTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Marie Rodriguez conducted a scheduled pre-licensing inspection and met with Licensee Jie Xu. Licensee has submitted an application for a change of location. Licensee currently operates under license #414004725. Home is a single story house with four bedrooms and two bathrooms that the Licensee rents. Residing in the home are the Licensee, his wife, and his minor child. Hours of operation will be Monday to Friday from 8:00am to 6:00pm.

LPA and Licensee inspected entire home for health and safety hazards. Daycare Areas: Living room, bedroom #2, bathroom #1, and backyard. Kitchen, dining room, and laundry room will only be used to pass through to go into the backyard. Off Limit Areas: Kitchen, dining room, bedroom #1, bedroom #3, bedroom #4, bathroom #2, garage, and front yard. 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 a working telephone, a fully charged fire extinguisher, and a smoke and carbon monoxide detectors. First aid kit is fully stocked and accessible through the closet in the living room. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. Per Licensee, there are no firearms in the home. There are no bodies of water on the premises.

Licensee states he will conduct an emergency drill at least once every six months and will log drills. Licensee states discipline policy is redirection. Licensee's pediatric first aid/CPR certificate expires March 2025. Postings will be posted by the entrance of the home. Licensee was reminded 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 Licensee. Licensee was reminded that when operating at a large capacity, there must be a helper present.

Large Family Child Care License has been granted and is effective as of today, June 15, 2023.
Fire clearance inspection was conducted and granted on June 6, 2023.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2023
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: XU, JIE
FACILITY NUMBER: 414005016
VISIT DATE: 06/15/2023
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Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every two years for Licensee and staff. Training can be completed online at www.mandatedreporterca.com.

Licensee 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.

Licensee 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 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 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 Licensee 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 Licensee.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
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: XU, JIE
FACILITY NUMBER: 414005016
VISIT DATE: 06/15/2023
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PINs), 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 was conducted and report was reviewed with Licensee Jie Xu.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Marie Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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