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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004937
Report Date: 07/25/2024
Date Signed: 07/25/2024 04:04:08 PM

Document Has Been Signed on 07/25/2024 04:04 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:GAO, QIUYUFACILITY NUMBER:
414004937
ADMINISTRATOR/
DIRECTOR:		GAO, QIUYUFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(302) 766-0612
CITY:EAST PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 9DATE:
07/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:25 PM
MET WITH:Licensee, Qiuyu GaoTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On July 25th, 2024, at approximately 1:25pm Licensing Program Analyst (LPA) Tapia-Mandujano conducted an unannounced Annual and met with licensee, Qiuyu Gao. Upon arrival Licensee let LPA in through the front entrance of the facility. LPA disclose the purpose of the of the inspection. Present in the facility are Licensee, two assistants supervising 9 children (3 infants and 6 preschool age). At this time the licensee is within capacity limits. All adults living and working at the facility are fingerprint cleared and associated.

Licensee owns home, which is a three bedroom two bathroom house. Licensee lives in the home with adult partner and one minor children. The hours of operation are Monday-Friday from 8:30am-5:30pm. Daycare areas are: Living Room, Dining Room, Bathroom #1, Bedroom #2, and backyard. Licensee is currently not using Bedroom #2. OFF limit areas: Kitchen, Bedroom #1 and #3, Bathroom #2, Laundry Room (Pass thru only to backyard), Storage shed in backyard, Garage, and front yard/driveway. All off limit areas are properly barricaded.


LPA toured home for health and safety hazards. LPA observed the Day-care is clean, orderly with a variety of age-appropriate toys for children. The home has age-appropriate equipment available for children in care. All furniture inspected is in good repair. Home does not have a fireplace. Licensee does not have any pets. The home has no pools or bodies of water in the home. LPA reminded licensee of water safety hazards. Licensee was reminded that baby walkers, bouncers, jumpers and any other similar items are to not be used for children in care. LPA observed infant children to sleep in pack and play in the living room/hallway. LPA observed pack and play to be free of loose of objects and/or articles.


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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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Document Has Been Signed on 07/25/2024 04:04 PM - It Cannot Be Edited


Created By: Leslit Tapia-Mandujano On 07/25/2024 at 03:23 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: GAO, QIUYU
FACILITY NUMBER: 414004937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above as per licensee she is no longer safe slee logs for children under 24 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/26/2024
Plan of Correction
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LPA explained to licensee that safe sleep logs must be properly logged for all children until they are 24 months.

Licensee agrees to start doing the safe sleep logs and will send proof of recording the safe sleep logs via email to LPA Tapia-Mandujano.
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:Marie Rodriguez
LICENSING EVALUATOR NAME:Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024


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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: GAO, QIUYU
FACILITY NUMBER: 414004937
VISIT DATE: 07/25/2024
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Licensee has a fully stocked First Aid kit and was reminded to be aware of the expiration dates. There was a fully charged fire extinguishers, smoke alarms, and carbon monoxide alarms that are in working order. Per licensee, phone number listed for Licensee is current. Per Licensee, there are no weapons or firearms in the home.

LPA reviewed nine children's record and assistant records. Licensees Mandated reporter training expires on 08/2025 and Pediatric CPR/First Aid certification expires on 06/2026. Licensee's last emergency drill was conducted 6/2024. Emergency drills must be conducted at least every 6 months and be properly logged. All the required posting documentation, such as the facility license, Notification of Parental Rights and have been placed in a prominent area for parents or representatives to review.

This facility does not provide Incident Medical Services- IMS. At this moment, licensee does not have any children enrolled. LPA reminded licensee to maintain the storage of medication and equipment/supplies, and we will review children's, personnel, and administrative records when children are enrolled. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA information Line at (800) 514-0301 (voice) or (800) 514-0383 TTY) and line to publication. Commonly Asked Questions about Child Care Centers and ADA are available at: https://www.ada.gov/resources/child-care-centers/.

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 inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website atwww.cdss.ca.gov/inforesources/community-care-licensing/inspection-process


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SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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: GAO, QIUYU
FACILITY NUMBER: 414004937
VISIT DATE: 07/25/2024
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Licensee was reminded that all adults 18 and over, 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 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-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.

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, the licensee, Qiuyu Gao, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 07/25/24.

Deficiencies were cited today under CCR, Title 22, Div. 12, Chapt. 1.

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

Exit interview conducted and report was reviewed by licensee, Qiuyu Gao.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Leslit Tapia-Mandujano
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC809 (FAS) - (06/04)
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