<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004877
Report Date: 11/08/2022
Date Signed: 11/08/2022 03:57:24 PM

Document Has Been Signed on 11/08/2022 03:57 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:WONG, TRICIAFACILITY NUMBER:
414004877
ADMINISTRATOR:WONG, TRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 722-0128
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
11/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Tricia WongTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/8/2022 at 1:35PM. Licensing Program Analyst (LPA) Luis J. Gomez conducted an unannounced; complaint investigation and met with licensee, Tricia Wong. Purpose of report Case Management report is to cite deficiencies observed during the complaint inspection. LPA inspected facility with licensee for health and safety hazards.

At 1:45PM., Based on observations and interview, LPA confirmed licensee does not have one play yard or crib for each infant in care.

At 3:00PM, Based on record review and interview, LPA confirmed licensee/ helper is not maintained required infant napping logs, with documentation of each 15 minute check.

Based on today’s inspection, deficiencies were observed in areas evacuated according the Title 22 Division 12 of Ca. Code of Regulations and cited on the 809D. An exit interview and plan of correction was discussed with the Licensee, Tricia Wong and signature of this form acknowledges the receipt of these documents.



A copy of this report and appeal rights were reviewed and provided to the licensee. Notice of site visit was posted and shall remain posted for 30 days.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Luis Gomez
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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 2
Document Has Been Signed on 11/08/2022 03:57 PM - It Cannot Be Edited


Created By: Luis Gomez On 11/08/2022 at 03:07 PM
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: WONG, TRICIA
FACILITY NUMBER: 414004877

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited
CCR
102425(a)

1
2
3
4
5
6
7
102425(a) Infant Safe Sleep: (a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will ensure four play yards/ cribs are available for each infant in care by the due date: 11/14/2022
8
9
10
11
12
13
14
Based on observations and interviews, LPA confirmed licensee does not have one play yard or crib for each infant in care. This poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14
Proof of correction will be submitted to the department via email.
Type B
11/14/2022
Section Cited
CCR102425(j)(2)(d)

1
2
3
4
5
6
7
102425(j)(2)(d) Safe Sleep: Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: a.Date. b.Infant’s name. c.Time of each 15-minute check. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will maintain napping logs for all infants in care by the due date: 11/14/2022
8
9
10
11
12
13
14
Based on record review and interview, LPA confirmed licensee is not maintained required infant napping logs, with documentation of each 15 minute check. This poses a potential health and safety risk to children in care.
8
9
10
11
12
13
14
Proof of correction will be submitted to the department via email.
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:Cindy Interiano
LICENSING EVALUATOR NAME:Luis Gomez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2