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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004944
Report Date: 02/26/2025
Date Signed: 02/26/2025 12:14:31 PM

Document Has Been Signed on 02/26/2025 12:14 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/
DIRECTOR:		ZHANG, XIAO YANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 627-6358
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
02/26/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:56 AM
MET WITH:Xiao Yan ZhangTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On February 26, 2025, at approximately 8:45 a.m., Licensing Program Analysts (LPAs) Zeynep Basak and Winnie Ly conducted an unannounced annual inspection, met the licensee, Xiao Yan Zhang, and explained the purpose of the inspection.

LPAs observed the licensee and the assistant were supervising four children (2 infants, 3 preschoolers). The licensee complies with the licensing capacity during the time of inspection. The children’s roster had been reviewed and was found to be complete and up to date.

The licensee owns a three-bedroom home and stated that two adults live there. LPA verified with the Guardian Roster that all present/live-in adults have criminal clearance. Per the licensee, the Child Care Home's operational hours are Monday through Friday, from 8:00 a.m. to 5:30 p.m.

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.

According to the licensee, there have been no changes to the previously approved childcare areas and off-limits areas. LPAs observed two storage rooms are not locked and discussed it with the licensee. Xiao stated she will install a child lock and provide a proof to the licensee via email by tomorrow.

LPAs observed the home to be clean and in good repair with proper temperature and ventilation. LPAs observed a combo smoke alarms and carbon monoxide detectors in the hallway, and two fully charged fire extinguisher in the size of 2A:10BC in the storage room.

See page 2.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Zeynep Basak
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 02/26/2025
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LPAs observed the childcare home to have a functioning telephone and verified contact information. Per the licensee, there is no firearm in the home. The licensee stated that they provide breakfast, a.m. snack, lunch, and early dinner in addition to drinking water.

LPAs and the licensee inspected the childcare areas for health and safety hazards. LPAs observed the daycare area to be clean, with all outlets covered. LPAs observed that all cleaning supplies and chemicals were properly stored and inaccessible to children. LPAs observed the daycare area to be equipped with age-appropriate furniture, toys, books, and educational materials.

LPAs observed five play yards, mats, individual sheets and blankets in the napping area. The licensee verified that children bring their own sheets and blankets from home. LPAs observed loose sheets and sleep sack in the play yard and discussed it with the licensee. The licensee stated she will buy new sheets that is fit in the bed and tight. A Technical Assistance will be issued. The licensee was informed about maintaining a sleep log to check on infants every 15 minutes during naptime. The licensee acknowledged that no baby walkers, bouncers, or similar items are used during daycare hours. LPAs observed a fireplace in the daycare area which was properly barricaded.

LPAs inspected the children’s bathroom and observed it to be clean and sanitary, with no chemicals within the children’s reach. LPAs inspected the outdoor play area for health and safety hazards and observed sufficient toys and play materials in the backyard for children. LPAs confirmed with the licensee that an isolation area is available in the front porch for ill children while waiting for their guardians to arrive. The licensee confirmed that no children currently have allergies or require medication.

LPAs reviewed seven children’s files and found two of the children did not have an immunization record in the file. The licensee contacted the parent to send the results, and the licensee will provide a proof to the LPA by tomorrow. LPA observed that all other required records were in the file, including Emergency Cards and Parental Rights forms.
LPAs reviewed the staff file and found that the licensee has a valid CPR and First Aid certification that issued on 8/2024 and a Mandated Reporter certificate that expires on 9/2026. LPAs observed the some of the immunization records and Mandated Reporter training certificates of the Assistan't not in the file.
See page 3.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Zeynep Basak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
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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: 02/26/2025
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LPAs discussed it with the licensee and she stated she will provide the records via email by tomorrow and LPAs provided information about a vendor who provides Mandated Reporter training in Chinese. The certificate of completion will be emailed to the LPA. A Type B violation will be cited for not being able to provide a record to review to the LPAs during the inspection.

Per the licensee, emergency drills are conducted at least once every six months, and the latest drill was conducted on February 7, 2025.
LPAs observed that all required forms and postings were displayed in the Child Care Home, including the License and Parent’s Rights Poster.
Per the licensee, the facility carries liability insurance for the daycare, and the copy was provided to LPA for placement in the physical file.

The licensee was reminded that all adults 18 years of age or older living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption as specified in Health and Safety Code Section 1596.871. This must occur prior to initial presence in a licensed Family Child Care Home. LPA informed the licensee that a civil penalty of $100 per person per day will be assessed for unqualified adults present for a maximum of five days. If this is a repeat violation, the penalty may increase to $500 per person per day after the fifth day.

LPA discussed the safe sleep regulations with the licensee and shared the Child Care Licensing Safe Sleep webpage located at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed the licensee about the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov. LPA recommended that the licensee register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

LPA also provided information about the MyChildCarePlan.org website, a consumer education resource that connects families with child care providers and Resource and Referral Agencies (R&Rs) throughout California.
See page 4.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Zeynep Basak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
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: 02/26/2025
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Incidental Medical Services (IMS) policy was discussed with the licensee. For additional information, LPA referred the licensee to PIN 22-02-CCP. LPA informed the licensee that when any IMS is provided, a Plan for Providing IMS must be submitted to the Department. Information regarding ADA compliance was also shared, including the toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY). A publication titled “Commonly Asked Questions about Child Care Centers and the ADA” is available at https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the inspection process, LPA informed the licensee that a survey may be sent to the email address on file. The licensee was encouraged to complete the survey and share her inspection experience. For additional information regarding the inspection process, the licensee was referred to the program website at https://www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.


A Type B violation, a Technical Violation, and a Technical Assistance were issued today.

During the inspection, the licensee confirmed that there are no registered sex offenders living in the facility. LPA completed the RSO profile in FAS.

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

The exit interview was conducted, and the report was reviewed with the licensee, Xiao Yan Zhang.
SUPERVISORS NAME: Daniel J Oquendo
LICENSING EVALUATOR NAME: Zeynep Basak
LICENSING EVALUATOR SIGNATURE:

DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/26/2025 12:14 PM - It Cannot Be Edited


Created By: Zeynep Basak On 02/26/2025 at 11:56 AM
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: ZHANG, XIAO YAN
FACILITY NUMBER: 414004944

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(d)
Personnel Records
(d) All personnel records shall be maintained at the child care home and shall be available to the licensing agency for review.

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 in providing records to the licensing staff to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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The licensee stated she will provide a proof to the LPA via email on 2/28/2025.
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:Daniel J Oquendo
LICENSING EVALUATOR NAME:Zeynep Basak
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2025


LIC809 (FAS) - (06/04)
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