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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004944
Report Date: 03/22/2024
Date Signed: 03/22/2024 12:37:25 PM

Document Has Been Signed on 03/22/2024 12:37 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:ZHANG, XIAO YANFACILITY NUMBER:
414004944
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
03/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Licensee, Xiao Yan ZhangTIME COMPLETED:
12:50 PM
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On 3/22/2024, at approximately 10:40AM, Licensing Program Analyst (LPA) Jonathan Tse conducted an unannounced annual and case management visit for an increase in capacity at the facility. LPA was granted entry to the facility by Licensee, Xiao Yan Zhang. LPA explained the purpose of the visit. Present during the visit was the Licensee, a helper (H1), and six preschool age children. The facility is in compliance with capacity requirements on this day.

Daycare Areas: Living Room #1, Bedroom #1, Bathroom #1 (attached to Bedroom #1), and Bathroom #2.
Off-limits Areas: Living Room #2, Bedroom #2, Bedroom #3, Kitchen, Backyard, and Garage.

LPA inspected the home for any health and safety hazards. LPA observed the home to be in clean and orderly condition. The home is equipped with a fully charged 3A40BC fire extinguisher. There is a carbon monoxide detector present in the home. The fireplace in Living Room #1 is obstructed by furniture and is inaccessible to children in care. There are age-appropriate toys and learning materials present in Living Room #1. LPA observed medications to be stored in labeled containers that are out of reach of children in care. Children nap on mats that are provided by the facility. Bedding is brought from home and cleaned once a week. LPA observed bedding to be stored in labeled cubbies for each child. The facility provides morning snack, lunch, and an afternoon meal. Per Licensee, there are no firearms or weapons in the home. There are no pools or other bodies of water in the facility.

LPA observed a map of emergency exits to be posted in Living Room #1. There is a manual fire alarm present. Fire clearance was granted on 3/13/2024. The facility has met requirements to be approved as a Large Family Child Care Home (FCCH) with a capacity of up to 14 children. LPA discussed capacity requirements of a Large FCCH with Licensee.

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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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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: ZHANG, XIAO YAN
FACILITY NUMBER: 414004944
VISIT DATE: 03/22/2024
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The Backyard is currently not licensed for daycare purposes. During the visit, Licensee requested the addition of the Backyard. LPA inspected the Backyard for any health or safety hazards. The Backyard is free of debris and other loose materials. There were age-appropriate toys and equipment present. Per Licensee, the Kitchen and Living Room #2 will only be used as pass-through areas for taking the children from Living Room #1 to the Backyard. LPA requested the addition of a fence or childproof gate in the Backyard to minimize the risk of children falling or tripping. Licensee agreed.

LPA reviewed two personnel records, six children’s files, and facility records. Licensee’s First Aid/CPR training expires 7/2024. LPA discussed requirement to maintain Mandated Reporter Training for all adults working with children in the home. LPA observed all children’s files to be complete. All required postings were observed to be posted and accessible for review in Living Room #1. Licensee carries liability insurance for the facility.

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 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.






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SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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: ZHANG, XIAO YAN
FACILITY NUMBER: 414004944
VISIT DATE: 03/22/2024
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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.

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.

LPA will recommend the approval of a large capacity license for this facility.
Licensee shall install a childproof gate in the Backyard and submit proof to LPA via email.

No deficiencies were cited during today’s visit on 3/22/2024.
A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Xiao Yan Zhang.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jonathan Tse
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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