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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384004293
Report Date: 09/14/2021
Date Signed: 09/14/2021 02:46:40 PM

Document Has Been Signed on 09/14/2021 02:46 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:FANG, JENNIFERFACILITY NUMBER:
384004293
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jennifer FangTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Yee, conducted an annual inspection today. Present at the facility are the licensee, Jennifer, her helper Meigui and 5 children. Meigui fingerprint is on pending status. The purpose of the inspection was explained. Hours of operations are Monday to Friday, 8:00 am - 5:30 pm. Daycare areas (street level): Front yard, infant room, bathroom, art room, and living room. The remaining areas are off-limit.

LPA and Licensee inspected the daycare areas for health and safety hazards. During the inspection, LPA observed the following: The daycare area is clean, orderly, and equipped with age-appropriate toys and equipment for the children. The home has adequate lighting and ventilation. The house has a working telephone, smoke alarm, carbon monoxide detector, and a fully charged fire extinguisher. First aid supplies are available for children. LPA reminded licensee of NO walkers, exersaucers, jumpers, bouncers and any similar items to be used for children in care and shall be made inaccessible. Licensee has been advised all adults, 18 years and older living in the home, helper, or assistant must have fingerprint clearance and must be associated to the facility by submitting a LIC 9182 with a copy of CDL or Ca. ID prior to having any contact with children in care failure to do so could result in an immediate civil penalty of $100.00 each day. Per Licensee, there are no firearms, weapons, or pets in the home. LPA observed no pools, spas, or other bodies of water on the premises. The Licensee had posted all the required forms (i.e., License, Notification of Parent's Rights, Earthquake preparedness checklist, and Notification of Personal Rights). Per Licensee, the last emergency drill was conducted on 8/31/2021. Some children's files are incomplete. A Child Care Provider's Guide to Safe Sleep was discussed. LIC9227 "Individual Infant Sleeping Plan" was discussed and provided. The provider shall supervise infants while sleeping, document and maintained in the infant's file. The documentation shall include the date, infant's name, time of each 15-minute check. A copy of the capacity worksheet was discussed and provided.

website: www.ccld.ca.gov. Title 22, Div 12, Chp3
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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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Document Has Been Signed on 09/14/2021 02:46 PM - It Cannot Be Edited


Created By: Jennifer Yee On 09/14/2021 at 02:13 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: FANG, JENNIFER
FACILITY NUMBER: 384004293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2021
Section Cited
CCR
102421(a)(b)

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102421(a)(b): Child's Records:
The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7)

This requirement was not met as evidence-based upon records review.
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The licensee needs to maintain children records in order by the due date, 9/28/2021
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The licensee failed to maintain current child's records.

This poses a potential health risk to children in care.
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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:Jennifer Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/14/2021 02:46 PM - It Cannot Be Edited


Created By: Jennifer Yee On 09/14/2021 at 02:19 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: FANG, JENNIFER
FACILITY NUMBER: 384004293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/15/2021
Section Cited
CCR
102370(d)(1)

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Type A: 102370 (d)(1)-Criminal Record Clearance-All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department.

Helper, Meigui requested LiveScan on 8/30/2021. However, the CCL database shows "pending status".
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The helper needs to wait for her fingerprint to be cleared before she can return to the daycare facility.

Follow-up visit will be conducted.
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This requirement is not met as evidenced by records review. This poses an immediate safety risk to children in care.
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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:Jennifer Yee
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2021


LIC809 (FAS) - (06/04)
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