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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414001763
Report Date: 11/27/2023
Date Signed: 11/27/2023 10:41:50 AM

Document Has Been Signed on 11/27/2023 10:41 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: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: 4DATE:
11/27/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee, Sherry KungTIME COMPLETED:
11:00 AM
NARRATIVE
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On 11/27/2023, at approximately 8:30AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced required inspection. LPA was granted entry to the facility by Licensee, Sherry Kung. LPA explained the purpose of the visit. Present in the facility were Licensee and four infants. The facility is in compliance with capacity requirements. The facility’s normal operating hours are from 8:30AM to 5:30PM.

The home is a single-level two-bedroom, two-bathroom home.

DAY CARE AREAS: Living Room, Dining Area, Bedroom #1, Bedroom #2, Bathroom #1, and Yard.
OFF-LIMIT AREAS: Bathroom #2 and Kitchen.

LPA inspected the home for any health and safety hazards. The home is kept in clean and orderly condition. Children are signed in and out via a sign-in/out sheet. There are age-appropriate toys and learning equipment in the Living Room for children. LPA observed cribs to be available for infant use. LPA observed a carbon monoxide detector and smoke detector to be operational. There is a fire alarm system running through the home. The home is equipped with a fully charged 2A10BC fire extinguisher. Cleaning supplies, poisons and other chemicals are stored inaccessible to children. All outlets are covered or obstructed by furniture to not be accessible to children. There is no fireplace in the daycare areas. All off-limits areas are barricaded and kept inaccessible to children. Per Licensee, there are no firearms kept in the home.

The yard is kept in clean condition. LPA did not observe any debris or other loose material to be present. There is sufficient cushioning for children. There is a storage unit located in the backyard that is off-limits and is kept locked to be inaccessible to children. The play equipment in the yard was observed to be clean and in good repair. There is a fence enclosing the yard that is at least five feet high. There are no pools or other bodies of water located in the facility.
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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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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Document Has Been Signed on 11/27/2023 10:41 AM - It Cannot Be Edited


Created By: Jonathan Tse On 11/27/2023 at 10:13 AM
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: KUNG, SHERRY LIU
FACILITY NUMBER: 414001763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two staff records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2023
Plan of Correction
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Licensee shall submit proof of completion of Mandated Reporter Training for Licensee and helper by set POC due date.
Type B
Section Cited
CCR
102416.1(a)
Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two staff records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2023
Plan of Correction
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Licensee shall submit proof of complete staff records to LPA by set due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/27/2023 10:41 AM - It Cannot Be Edited


Created By: Jonathan Tse On 11/27/2023 at 10:13 AM
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: KUNG, SHERRY LIU
FACILITY NUMBER: 414001763

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of four children's records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2023
Plan of Correction
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Licensee shall submit complete immunization records for the incomplete records to LPA by set due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Ali Zebila
LICENSING EVALUATOR NAME:Jonathan Tse
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2023


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: KUNG, SHERRY LIU
FACILITY NUMBER: 414001763
VISIT DATE: 11/27/2023
NARRATIVE
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LPA reviewed one staff file and four children’s files. All children’s files included emergency identification information and Notification of Parent’s Rights (LIC995A). Licensee’s First Aid/CPR Training expires 1/2024. Licensee’s Mandated Reporter Training expired 2/2023. LPA discussed requirement to maintain Mandated Reporter Training. LPA discussed requirement to maintain proper documentation in all employee’s files.

LPA observed the following documents to be posted: Facility License and PUB394, Notification of Parents’ Rights. The facility conducts emergency drills every three months. The facility prepares snacks and lunch for children.

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 [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/inspection-process.

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.

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-andresources/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.


Continued on Page Three
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
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: KUNG, SHERRY LIU
FACILITY NUMBER: 414001763
VISIT DATE: 11/27/2023
NARRATIVE
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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, Licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

See LIC809-D for deficiencies cited today. See LIC9102-TV for Technical Violations given today.

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

Exit interview conducted and report was reviewed with the licensee, Sherry Kung.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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