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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417487
Report Date: 03/01/2023
Date Signed: 03/01/2023 01:33:30 PM

Document Has Been Signed on 03/01/2023 01:33 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:LIU, YANFACILITY NUMBER:
013417487
ADMINISTRATOR:LIU, YANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 366-2332
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 7DATE:
03/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Yan LiuTIME COMPLETED:
01:40 PM
NARRATIVE
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On March 01, 2023 at approximately 9:00am Licensing Program Analyst (LPA) Haderer met with the licensee Yan Liu for the purpose of conducting an unannounced 1-year annual inspection for Health and Safety compliance. Present for today’s inspection was the licensee and 7 children in care (3 infants and 4 pre school age) Arrived during inspection was licensee fingerprint cleared and TB test cleared aunt and uncle helpers. Living in the home is the licensee, licensee’s fingerprint cleared and TB tested husband and two adolescent daughters. Hours of operation are Monday - Friday 8:30am 6:00pm.

The facility is a 3-level home with 4 bedrooms, 4 bathrooms, living room, dining room, kitchen, family room, attached 2-car garage, front, back and side yards. There is a conventional fireplace in the on-limits living room (day care area) screened and blocked by a small table. The home has heating and ventilation for safety and comfort. Per the licensee, the ISOLATION AREA will be in the on-limits living room area away from the other children in care.

ON LIMIT AREAS: Living room; house bathroom, short hallway to the bathroom; walk through family room to access the back yard; center portion of the backyard surrounded by small fencing to keep the children contained within it. Licensee was reminded that other than wipes or things used for the children in the on limits children’s bathroom, they need to be empty of most all items (or locked up) such as cleaning products.



OFF LIMIT AREAS: All 4 bedrooms in the home, kitchen, family room (except walk through to access back yard) and attached 2-car garage. The off-limit areas will be inaccessible by child gates, closed and/or locked doors and adult supervision.

The home has a fully charged 3A10BC fire extinguisher in the living room, smoke, and carbon monoxide detectors (tested and working) and a working telephone. Fire drills have been conducted every 6 months, however, drill log not present and available in the facility. See LIC 809D for deficiency.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2023
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LIU, YAN
FACILITY NUMBER: 013417487
VISIT DATE: 03/01/2023
NARRATIVE
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Licensee has ample age-appropriate toys and learning materials inside and outside the home. The outdoor play area has ample toys that are free from defects and dangerous conditions. Per licensee, there are no firearms in the home. Drop-down cribs are not allowed at the day-care facility. Toxins, medicines, and hazardous items were inaccessible during today's inspection.

LPA reviewed facility files including records for licensee and Children’s files. CPR/1st Aid was available for licensee, expires 3/20/2023. Mandated Reporter was completed on 3/17/2022. Licensee was reminded that CPR/1st Aide and Mandated Reporter is to be renewed every two years. The licensee owns the property but does not carry liability insurance.

Children’s files were reviewed. The facility roster was reviewed, and a copy obtained, but was incomplete due to children’s files missing for 4 of 7 children. Files were missing for 4 of the 7 children in care including: .LIC700 I.D. and Emergency Information; LIC627: Consent for Emergency Medical Treatment; LIC995: Parent’s Rights Receipt; Immunization Records; LIC282 Acknowledgement of no liability insurance. No sleep logs for infant children. See LIC809D for deficiencies.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LIU, YAN
FACILITY NUMBER: 013417487
VISIT DATE: 03/01/2023
NARRATIVE
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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-and-resources/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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.

There were 7 deficiencies issued today and 1 Technical Violation:

Deficiencies include:

- LIC700 ID and Emergency Contacts

- LIC627 Consent for Emergency Medical Treatment form

- LIC995A Parent’s Rights signed proof of Receipt

- Immunization Records

- LIC282 Acknowledgement of no Liability Insurance

- Disaster drill log not available

- No sleep logs available for infants up to age 2.

See LIC 809D for details.

Technical Violation issued to fix basement access door on patio

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

Exit interview conducted and report was reviewed with the licensee Yan Liu.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Russell Haderer
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 03/01/2023 01:33 PM - It Cannot Be Edited


Created By: Russell Haderer On 03/01/2023 at 11:54 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: LIU, YAN
FACILITY NUMBER: 013417487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that disaster drill log not present and available in the facility which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/02/2023
Plan of Correction
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Licensee will complete a disaster drill (fire or earthquake) and post the drill log near facility license to ensure location is known. Licensee will complete and document a disaster at least once every six months.

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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 03/01/2023 01:33 PM - It Cannot Be Edited


Created By: Russell Haderer On 03/01/2023 at 11:54 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: LIU, YAN
FACILITY NUMBER: 013417487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that sleep logs have not been completed for infants up to 24 months of age for 3 infants in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/03/2023
Plan of Correction
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Beginning this day (3-01-2023) Licensee will maintain 15 minute checks and document them in sleep logs for all infants up to 24 months. These records must be maintained every day and kept as a record for three years.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 6 of 7 children's files were missing immunization records which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
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Licensee will collect the missing immunization records for all children in care. Going forward these records will be collected and kept in the respective children's files.
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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 03/01/2023 01:33 PM - It Cannot Be Edited


Created By: Russell Haderer On 03/01/2023 at 11:54 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: LIU, YAN
FACILITY NUMBER: 013417487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 4 of 7 children in care files did not contain the LIC995A signed copy showing receipt of notice of parents rights which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
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Licensee will collect the missing LIC995 acknowledgement of receipt form for all children in care. Going forward these records will be collected and kept in the respective children's files.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 of 7 children in care files did not contain the LIC700 ID and Emergency Contact form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
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Licensee will collect the missing LIC700 ID Emergency Contact information forms for all children in care. Going forward these records will be collected and kept in the respective children's files.
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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 03/01/2023 01:33 PM - It Cannot Be Edited


Created By: Russell Haderer On 03/01/2023 at 11:54 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: LIU, YAN
FACILITY NUMBER: 013417487

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that 4 of 7 children in care did not have the LIC627 Consent for Emergency Medical Treatment form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
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Licensee will collect the missing LIC627 Consent for Emergency Medial Treatment forms for all children in care. Going forward these records will be collected and kept in the respective children's files.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the licensee did not comply with the section cited above in that 6 out of 7 children in care files did not contain the signed LIC282 Acknowledgement of no Liability Insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
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3
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Licensee will collect the missing LIC282 Acknowledgement of no Liability Insurance forms for all children in care. Going forward these records will be collected and kept in the respective children's files.
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:Chandra Charles
LICENSING EVALUATOR NAME:Russell Haderer
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2023


LIC809 (FAS) - (06/04)
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