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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414005073
Report Date: 02/27/2024
Date Signed: 02/27/2024 11:55:13 AM

Document Has Been Signed on 02/27/2024 11:55 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:MAI, JIAWENFACILITY NUMBER:
414005073
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
02/27/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Applicant, Jiawen MaiTIME COMPLETED:
12:10 PM
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On 2/27/2024, at approximately 8:30AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an announced pre-licensing visit at this home. LPA was granted entry to the home by Applicant, Jiawen Mai. LPA explained the purpose of the visit. Present during the visit was the Applicant, Applicant’s spouse, and Applicant’s child.

The home is a single-story, five-bedroom, four-bathroom home.

Daycare Areas: Bedroom #1, Bathroom #1, Living Room, Dining Room, Front Yard.
Off-limits Areas: Bedroom #2, Bedroom #3, Bedroom #4, Bedroom #5 (used as Office), Bathroom #2, Bathroom #3, Bathroom #4, Kitchen, Backyard, Storage Shed in Backyard, Side Yard, and Garage.

LPA inspected the home for any health and safety hazards. LPA observed the home to be in clean and orderly condition. The home is equipped with a combination smoke and carbon monoxide detector that is operational. There is a fully charged 3A40BC fire extinguisher stored in the kitchen and is easily accessible. There is an electric fireplace present in the Living Room that is covered and secured. All electrical outlets are covered or otherwise obstructed by furniture to be inaccessible to children. Poisons, cleaning detergents, and other chemicals are stored inaccessible to children. Per Applicant, there is a firearm in the home that is locked and stored appropriately. All off-limits areas are secured by childproof gates or locks.

LPA observed age-appropriate toys and learning materials to be present in the Living Room and Bedroom #1. Bedroom #1 is intended to be used as a play area as well as an infant napping area. Per Applicant, they will be acquiring cribs for infants to be used in Bedroom #1. LPA discussed safe sleep requirements with Applicant, including keeping cribs free of clothing and other loose articles, documentation of sleep logs, and required licensing forms. Applicant's First Aid/CPR expires 9/2024, and Mandated Reporter Training expires 11/2024.

Continued on Page Two
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2024
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 3
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: MAI, JIAWEN
FACILITY NUMBER: 414005073
VISIT DATE: 02/27/2024
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LPA observed the Front Yard to be free of debris. There is cushioning available in the form of artificial turf. There is a play structure that is currently placed on dirt. LPA discussed the placement of mats or cushioning underneath the play structure with Applicant. Per Applicant, they will be installing cushioning underneath the play structure. The Front Yard is enclosed by a fence that is at least five feet high. There are no pools or other bodies of water present in the home.

Per Applicant, infants will be provided food and milk from home. Preschool age children will be provided lunch and AM/PM snacks. Applicant plans on operating from 8:00AM to 5:30PM.

Applicant was reminded baby walkers, bouncers, jumpers, and any other similar items are not to be used for children in care. LPA discussed with Applicant that emergency disaster drills are to be conducted and documented at least once every six months. Applicant was notified that any changes to daycare areas or off-limits areas must be approved by the Department.

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, 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.

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) or (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.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
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: MAI, JIAWEN
FACILITY NUMBER: 414005073
VISIT DATE: 02/27/2024
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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 purchased equipment.

On this date, 2/27/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, 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.

Prior to licensure, Applicant shall provide to LPA via email:
1) Proof of required immunizations (MMR, Tdap, and influenza)
2) Proof of cribs to be used for infants
3) Proof of finalized layout of daycare areas

Exit interview conducted and report was reviewed with the applicant, Jiawen Mai.

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 platforms.
To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/ subscribe and select the Child Care option to receive email communication.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC809 (FAS) - (06/04)
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