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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005016
Report Date: 07/02/2026
Date Signed: 07/02/2026 03:14:19 PM

Document Has Been Signed on 07/02/2026 03:14 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:XU, JIEFACILITY NUMBER:
414005016
ADMINISTRATOR/
DIRECTOR:		XU, JIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 338-8177
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
07/02/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Licensee, Jie "Jay" XuTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On July 2, 2026, at approximately 1:15PM, Licensing Program Analysts (LPAs) Tse and Tran conducted an unannounced annual visit at the facility. LPAs met with Licensee, Jie “Jay” Xu, and explained the purpose of the visit. Present during the visit was the Licensee, Licensee’s spouse, 3 infants, and 3 preschool age children. The facility is operating within staffing and ratio requirements on this day. The facility’s hours of operation are from 8:00AM to 6:00PM, Monday to Friday.

Daycare Areas: Living Room, Bedroom #2 (Napping Room), Bathroom #1, and Backyard.
Off-limits Areas: Kitchen, Dining Room, Bedroom #1, Bedroom #3, Bedroom #4, Bathroom #2, Garage, and Front Yard.

LPAs and Licensee inspected the home for any health or safety hazards. There is a fully charged 3A40BC fire extinguisher present. There are carbon monoxide detectors present in the home. There is a fireplace in the Living Room that is blocked with furniture. Electrical outlets are covered or blocked with furniture when not in use. There are heating and ventilation controls available for the comfort and safety of children in care. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children in care. There is a first aid kit present.

LPAs observed there to be age-appropriate toys and learning materials. Furniture was observed to be age-appropriate and free of rough or sharp edges. There are play yards and cots available for napping children. Bedding is brought from home and taken back once a week for cleaning. Per Licensee, all meals are provided by the facility. Water bottles are brought from home and refilled at the facility. Licensee stated that there are currently no children enrolled who have food allergies or who need medications. Storage of medication was discussed. If medication is needed, then it will be kept in a closet next to the Living Room that is inaccessible to children in care.
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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2026
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: XU, JIE
FACILITY NUMBER: 414005016
VISIT DATE: 07/02/2026
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Upon entry to the home, LPAs observed that the door to Bedroom #2 was closed. There were 3 infants napping in Bedroom #2, and no provider was present inside the room. LPAs informed Licensee that a deficiency shall be cited. The door to a room with napping infants inside shall be kept open such that a provider may see all napping infants without having to move the door. This is not required if a provider is stationed inside the room with the napping infants.

The Backyard was observed to be enclosed by a fence that is at least 4 feet high. The Backyard is free of debris and other loose materials. There are age-appropriate toys and equipment present. Children are taken out to play at least twice a day. There are no swimming pools or other similar bodies of water present. Per Licensee, there are no firearms or weapons stored in the home.

LPAs reviewed 2 staff files, 9 children’s files, and facility records. Licensee’s Pediatric First Aid/CPR training is current and expires April 2027. Mandated Reporter training certificates are current and available for review. Children’s files were observed to be complete. Licensee carries liability insurance.

Infant sleep logs were observed to not be maintained. LPAs advised that infant sleep logs must kept current and updated while infants are napping. A deficiency shall be cited today.

Required postings were posted and accessible for review. The facility last conducted an emergency drill on May 13, 2026. Drills are properly logged and documented. A facility roster is available for review. Capacity requirements were discussed.

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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NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
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: XU, JIE
FACILITY NUMBER: 414005016
VISIT DATE: 07/02/2026
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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-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.

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, the Licensee, Jie Xu, 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 deficiencies cited 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, Jie “Jay” Xu.
NAME OF LICENSING PROGRAM MANAGER: Ali Zebila
NAME OF LICENSING PROGRAM ANALYST: Jonathan Tse
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/02/2026 03:14 PM - It Cannot Be Edited


Created By: Jonathan Tse On 07/02/2026 at 02:50 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: XU, JIE
FACILITY NUMBER: 414005016

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having the door to the napping room closed while infants are napping inside, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
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The door to the napping room shall remain open while infants are napping inside. Licensee shall verify that the door to Bedroom #2 remains open while infants are napping. This shall be documented and verified in addition to the 15-minute sleep checks.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation record review, the licensee did not comply with the section cited above by not maintaining current infant sleep logs which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
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Sleep logs shall be =conducted and maintained. Sleep logs for 3 consecutive days shall be submitted to LPA via email by July 25, 2026.
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: 07/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2026


LIC809 (FAS) - (06/04)
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