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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001763
Report Date: 02/17/2022
Date Signed: 02/17/2022 11:06:52 AM

Document Has Been Signed on 02/17/2022 11:06 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:KUNG, SHERRY LIUFACILITY NUMBER:
414001763
ADMINISTRATOR:KUNG, SHERRY LIUFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 570-6966
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 5DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Sherry KungTIME COMPLETED:
11:15 AM
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On February 17, 2022 at 9:00am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, annual, required inspection. LPA met with licensee, Sherry Kung and explained the purpose of the inspection. Present in the home were licensee, licensee's two helpers (H1 and H2) and 2 enrolled children (1 infant and 2 preschool age). Facility is operating within capacity limits and ratio on this date.

All adults living and/or working in the home have a criminal record clearance on file. Hours of operation are Monday to Friday from 8:30am to 5:30pm. Licensee owns the home which is a one level, single family home. The DAY CARE AREAS are the living room/dining area, bathroom #1, bedroom #1, bedroom #2, and front yard. The OFF-LIMIT AREAS are the kitchen and bathroom #2. Off limit areas are barricaded with locked doors and/or child safety gates.

At approximately 9:15am, LPA toured day care areas of home with Licensee. LPA observed home to be in good repair with proper temperature and ventilation. There were a variety of age appropriate toys and equipment in the home which were in good condition. All cleaning supplies, poisons and other chemicals were stored inaccessible to children behind child safety locked cabinets. LPA observed facility to have a baby ex-saucer stored in living room/day care area that was not in use. LPA reminded licensee baby ex-saucers are not to be used and must be removed from a facility. Licensee stated she understood and will remove the ex-saucer.

At approximately 9:30am, additional enrolled child (preschool age) arrived to facility. LPA did not observe any pools, spas or bodies of water on the property. The outdoor area is enclosed with an least 5ft high fence. The outdoor area is equipped with a variety of toys and equipment that are in good working condition. At approximately 9:45am, additional enrolled child (preschool age) arrived to facility.

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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: KUNG, SHERRY LIU
FACILITY NUMBER: 414001763
VISIT DATE: 02/17/2022
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There was a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher and a working telephone on site. Phone number listed for Licensee is current. Per Licensee, there are no weapons or firearms in the home. LPA reviewed all four children’s records which were complete. Children’s files have a record of emergency identification information on file. LPA was unable to review H1 and H2's files as their immunizations were not present in the home and only partially available on a mobile device. LPA reminded licensee any helper having direct contact with the children must have their required immunization readily available for an LPA's review. Licensee to provide LPA proof of H1 and H2's complete immunizations no later than 02/25/2022.

Licensee’s Pediatric First Aid/CPR is current and will expire 01/2024. Last emergency drill conducted 01/10/2022. Emergency drills are conducted at least once every six months and are properly logged.

During Inspection:
- Licensee was given information regarding PIN 20-24-CCP Safe Sleep Regulation, CA DPH Guidance for Use of Face Coverings, Receiving Important Updates, and Lead Poisoning Facts Flyer.
-Licensee was reminded, as of September 1, 2016, all Staff and Volunteers must provide proof of immunization against pertussis, measles, and influenza, or qualifies for an exemption, pursuant to Health and Safety code 1596.7995 and 1597.622.
-Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years by all staff hired. Training can be taken online at www.mandatedreporterca.com.
-Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
-Licensee was advised for any additional questions to contact CCLD office, Monday to Friday, 8:00am - 5:00pm, (650) 266-8800 or 1 (844) 538-8766. Website: www.cdss.ca.gov.

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
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: KUNG, SHERRY LIU
FACILITY NUMBER: 414001763
VISIT DATE: 02/17/2022
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: www.ada.gov/childqanda.htm.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email to [email protected]. 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/process.

Licensee was reminded that all adults 18 and over living or working in the home, 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 purchased equipment.

No deficiencies were cited today under CCR, Title 22, Div. 12.

A notice of site visit was given and must remain posted for 30 days.

An exit interview conducted and report was reviewed with the licensee, Sherry Liu Kung.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
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