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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004997
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:42:39 PM

Document Has Been Signed on 04/04/2024 02:42 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:SHU ACADEMY SAN CARLOSFACILITY NUMBER:
414004997
ADMINISTRATOR/
DIRECTOR:		SHEN, TINGFACILITY TYPE:
850
ADDRESS:1601 LAUREL STREETTELEPHONE:
(650) 866-9190
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 55TOTAL ENROLLED CHILDREN: 37CENSUS: 33DATE:
04/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Yun Li & Ting ShenTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On April 4th 2024 Licensing Program Analyst (LPA) Kassandra Medrano conducted an unannounced, case management inspection regarding lead testing for childcare centers. LPA met with Yun "Mia" Li, School Director,and Ting "Katie" Shen, Executive Director and explained the purpose of the inspection. Present during the inspection included 33 children and 9 staff including the director. Later during visit it was found, that three staff were in process on guardian for criminal record clearance. Based on review of documentation it was found that 2 of the three did not have clearance, and the other had received clearance from a previous facility and is still in process for their most recent fingerprinting. During visit, the two individuals were removed from facility during visit. Katie stated that calls were attempted on 3/11/2023, and she stated that she was advised to wait for clearance for S2. As well as the same conversation was had on 3/27/23 for S1 and S2. But there was no written documentation of these calls. Based on review of water board site facility does not have a lead sampling on file. During conversation with Ting "Katie" Shen, she stated that site has tested on 3/2/23 but was associated to another license number (414001894). Facility was licensed 6/19/23, and had 180 days post licensing to complete. During visit, facility representatives provided LPA with documentation of testing. LPA advised that lead testing results and LIC forms 9275, 9276 and 999 should be posted.
Exit interview was conducted and report was reviewed by, Executive Director, Ting Shen.
LICENSEE MUST POST ANY TYPE A DEFICIENCIES DURING TODAYS VISIT WITH THE NOTICE AND LICENSEE UNDERSTANDS THE NOTICE AND TYPE A DEFICIENCIES MUST REMAIN POSTED FOR THIRTY DAYS. REQUIREMENTS FOR AB 633 FACT SHEET AND A COPY OF ACKNOWLEDGEMENT OF RECEIPT OF LICENSING REPORTS (LIC 9224) WERE DISCUSSED WITH APPLICANT/PROVIDER. PROVIDER UNDERSTANDS THIS REQUIREMENT.

This TYPE A citation page shall be posted for 30 days along with the “Notice of Site Visit.” This page shall be provided to all parents of children currently enrolled, and any future children being enrolled for the next 12 months per AB 633 requirements.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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Document Has Been Signed on 04/04/2024 02:42 PM - It Cannot Be Edited


Created By: Kassandra Medrano On 04/04/2024 at 01:05 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: SHU ACADEMY SAN CARLOS
FACILITY NUMBER: 414004997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/05/2024
Section Cited
CCR
101170(e)

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e) 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:(1) Obtain a California clearance or a criminal record exemption as required... This requirement was not met as evidenced by:
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Staff were removed and will not return until clearances are granted.
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Based on record review and observations S1 and S2 were present in the facility and did not have clearances associated to profiles.
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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:Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2024


LIC809 (FAS) - (06/04)
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