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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
384004293
Report Date:
09/29/2021
Date Signed:
09/29/2021 12:51:26 PM
Document Has Been Signed on
09/29/2021 12:51 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, JENNIFER
FACILITY NUMBER:
384004293
ADMINISTRATOR:
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
CITY:
STATE:
ZIP CODE:
CAPACITY:
8
TOTAL ENROLLED CHILDREN:
0
CENSUS:
5
DATE:
09/29/2021
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
12:30 PM
MET WITH:
Jennifer Fang
TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Yee conducted a follow-up inspection today. Present at the facility are 5 children and a licensee. The deficiencies cited on 9/14 have been corrected.
SUPERVISORS NAME
:
Ali Zebila
LICENSING EVALUATOR NAME
:
Jennifer Yee
LICENSING EVALUATOR SIGNATURE
:
DATE:
09/29/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/29/2021
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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