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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004853
Report Date: 11/15/2021
Date Signed: 11/15/2021 03:05:26 PM

Document Has Been Signed on 11/15/2021 03:05 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:YANG, QIAOLINGFACILITY NUMBER:
414004853
ADMINISTRATOR:YANG, QIAOLINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 489-5707
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
11/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Quioling YangTIME COMPLETED:
03:15 PM
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On November 15, 2021, Licensing Program Analyst (LPA) Cowan met with applicant Quioling Yang for an announced subsequent Pre-Licensing inspection. This inspection was to inspect the rear storage spaces in the back yard of the home. LPA observed that both rooms are being used for storage.

Upon the clearance of fingerprints for all adults in the home, LPA recommends licensure for applicant.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2021
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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