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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417487
Report Date: 03/16/2023
Date Signed: 03/16/2023 02:16:46 PM

Document Has Been Signed on 03/16/2023 02:16 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:
03/16/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Yan LinTIME COMPLETED:
02:30 PM
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On March 16, 2023 at approximately 1:10pm Licensing Program Analysts (LPA) R. Haderer A. Elliott met with the licensee Yan Liu for the purpose of on site visit to clear seven deficiencies found during the March 1, 2023 inspection. Present today is the licensee and 7 children in care (3 infants and 4 pre school age).

Deficiencies issued included:
Missing documents in children's files for:
- 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

Other deficiencies:

- Disaster drill log not available

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


All deficiencies were cleared this day. Deficiency clearance letters were printed and issued.

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: 03/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2023
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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