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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004342
Report Date: 11/17/2021
Date Signed: 11/17/2021 01:22:14 PM

Document Has Been Signed on 11/17/2021 01:22 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:WU, XIU LINGFACILITY NUMBER:
384004342
ADMINISTRATOR:WU, XIU LINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 324-9002
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
11/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Xiu Ling WuTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Yee conducted an annual inspection today. The purpose of the inspection was explained. Present at the facility are licensee Xiu Ling, her husband, and 5 daycare children (3 infants, 2 preschoolers). Current residents are Xiu Ling, her husband, and their 9 years old daughter. The facility personnel summary report was reviewed with Xiu Ling and she said it's correct. Days and Hours of operation are M -F, 6 AM- 6 PM.

LPA and the Licensee inspected the home for Health and Safety Hazards. The daycare areas are the Living Room & Dining area, the bedroom, the bathroom, the small private backyard, and the large community-shared yard. The off-limit area is the kitchen. The off-limit areas are adequately barricaded or have a child-proof doorknob installed. The home is clean and in good repair with sufficient lighting and ventilation. The home is equipped with a carbon monoxide, smoke alarm, and fire extinguisher. The home has age-appropriate toys and equipment available for children. All harmful objects, including chemicals, disinfectants, and sharp objects, are made inaccessible to children. There are no bodies of water in the facility. There are no firearms, weapons, or pets in the home. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. When any IMS is provided, an updated Plan of Operation that includes 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
The licensee has current CPR & 1st Aid until 3/1/2022. Child Abuse Mandated Reporter Training, AB1207 certificate is on file. Children's records were reviewed. Safe sleep guideline was discussed. "Individual Infant Sleeping Plan" LIC9227 is on file.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2021
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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