Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002600
Report Date: 10/12/2016
Date Signed 10/12/2016 10:30:40 AM

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:YAN, MEI RONGFACILITY NUMBER:
384002600
ADMINISTRATOR:YAN, MEI RONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 278-1033
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 10DATE:
10/12/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mei Rong YanTIME COMPLETED:
10:50 AM
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Licensing Program Analyst, LPA Yee met with Ms. Mei Rong Yan, her mom and 10 day-care children. Day-care areas (upstairs level only): living room, family room, kitchen, bathroom, and backyard. The remaining areas are off limit. Current residents in the home are Mei Rong, her mother, and her daughter. All adults have finger print clearance. CPR and first aid is current which expires 3/6/2018. The home is clean and orderly. Children files were reviewed. Facility serves snacks and lunches. Incidental Medical Services plan, IMS was discussed. The home is ventilated properly. Immunization requirements was discussed. Staffing, ratio and capacity was discussed.

Facility is in compliance today.

website: www.ccld.ca.gov. Title 22, Div 12, Chp 3

Office: (650) 266-8800
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jennifer YeeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2016
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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