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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004595
Report Date: 08/31/2022
Date Signed: 08/31/2022 11:11:50 AM

Document Has Been Signed on 08/31/2022 11:11 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:WANG,YANFACILITY NUMBER:
384004595
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
08/31/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Yan WangTIME COMPLETED:
11:30 AM
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Licensing Program Analyst, LPA Yee conducted a pre-licensing inspection today. LPA met with applicant, Yan Wang. LPA and Yan inspected the entire home. Per Yan she will be the only person living at this location. She only rents the upper level. The lower level belongs to the owner. She does not plan to have roommate or tenant at the facility. LPA informs her that any residents/helpers living or working at the facility must have fingerprint clearance prior to living or working here. She said she understands. The lease agreement is on file. Days and hours of operation: Monday to Friday between 8:00 AM to 6:00 PM.

Day Care Areas (upper level): living room, kitchen, hallway bathroom, and bedroom #1. The off-limit area: bedroom #2, master bedroom, master bathroom, the entire lower level, and the backyard. The home is equipped with a smoke detector and the fire extinguisher size 2A10BC. LPA advised the applicant to conduct emergency drills once every six months and keep a log sheet. The facility does not have pets or body of water such as swimming pool, hot tub. Discipline policy was discussed. The facility will provide morning snacks, lunches and afternoon snacks.

The applicant has required immunization records on file. The 8 hours Health and Safety certificate is on file. CPR and 1st aid are current until 5/15/2023.

LPA review AB 1207 with the Licensee. As of January 1, 2018, all staff members are required to complete Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com. AB 1207 certificate for the applicant is on file. The Child Abuse Mandated Reporter Training was completed on 10-21-2021.

Incidental Medical Services (IMS) policy was discussed. This facility plans to provide Incidental Medical Services - IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 102417. 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

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: WANG,YAN
FACILITY NUMBER: 384004595
VISIT DATE: 08/31/2022
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The 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, before 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 the 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 the 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.

LPA reviewed with the 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.
Individual Infant Sleeping Plan (LIC9227) form was provided. Technical support for COVID was discussed. Website for forms and regulations: www.ccld.ca.gov.

LPA informed the applicant that as a licensee, she shall be present in the home and shall ensure that children are supervised at all times. Temporary absences shall not exceed 20 percent of the hours of the operation. During the time of that 20 percent absence, the facility shall arrange for a substitute adult to care and supervised the children.

Prior to licensure, the facility needs to complete the following:

1) A carbon monoxide detector. 2) Government issued photo ID needs to reflect the current address.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2022
LIC809 (FAS) - (06/04)
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