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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419798
Report Date: 07/28/2021
Date Signed: 07/28/2021 11:21:23 AM

Document Has Been Signed on 07/28/2021 11:21 AM - 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:SU, NANCYFACILITY NUMBER:
013419798
ADMINISTRATOR:SU, NANCYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 668-0312
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nancy SuTIME COMPLETED:
11:35 AM
NARRATIVE
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On 7/28/2021 at 8:30am, Licensing Program Analyst (LPA) Jonathan Williams met with Licensee for a Required 1 Year Inspection. Present for this inspection are the Licensee, three children in care (two preschool-aged and one infant), and the Licensee's adult son who, per Licensee, does not have a valid fingerprint clearance. The facility was toured to conduct a health and safety inspection.

On limit areas: Kitchen, eating area, first bathroom down the hallway, bedroom facing the eating area, backyard area.
Off limit areas: Garage, master bedroom/bathroom, two bedrooms located down the hallway, backyard area blocked off by fence.
Isolation area: Bedroom facing the eating area.

At 8:30am, LPA toured the interior of the home. LPA observed there to be toys and learning materials in the facility. Per Licensee, there are no firearms kept in the home. At 8:40pm, LPA toured the facility bathroom. Toilets and sinks were found to be in operable condition. LPA observed adequate amounts of paper towels and hand soap available to children in the bathroom during today's inspection. No cleaning supplies were observed to be accessible to children in the bathroom during today's inspection.

At 8:45am, LPA toured the backyard. There are no pools, ponds, hot tubs, or any other bodies of water in the on-limit areas of the backyard during today's inspection. There is an empty pool in the off-limit area of the backyard which is kept inaccessible to children by fencing which opens outward. Play equipment was observed to be age-appropriate and in operable condition. LPA observed there to be broken wood beams accessible to children in the on-limit area of the backyard.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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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Document Has Been Signed on 07/28/2021 11:21 AM - It Cannot Be Edited


Created By: Jonathan Williams On 07/28/2021 at 09:02 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: SU, NANCY
FACILITY NUMBER: 013419798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
07/28/2021
Section Cited
CCR
102370(d)(1)

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(d) All individuals subject to a criminal record review... shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department
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Licensee shall submit LiveScan request for unfingerprinted adult immediately. Licensee shall either exclude son from facility or cease operation immediately until clearance is obtained.
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This requirement was not met as evidenced by: Based on Licensee statement, Licensee's adult son, who lacks fingerprint clearance, has been living in the faciltiy for a period of two months. This poses an immediate risk to the health and safety of children in care. $500 civil penalty assessed today.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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:Wynn Norona
LICENSING EVALUATOR NAME:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2021 11:21 AM - It Cannot Be Edited


Created By: Jonathan Williams On 07/28/2021 at 10:04 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: SU, NANCY
FACILITY NUMBER: 013419798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2021
Section Cited
CCR
102417(g)(4)

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(4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
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Licensee shall ensure detergents and cleaning compounds are made inaccessible to children by the POC due date.
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This requirement was not met as evidenced by: Based on LPA observation, detergents and cleaning compounds were accessible to children due to unlocked door. This poses a potential risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
08/04/2021
Section Cited
CCR102417(g)(7)

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(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.
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Licensee shall obtain emergency information documentation as required by 102417(g)(7) and maintain copies at facility for LPA review.
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This requirement was not met as evidenced by: Based on Licensee statement, emergency information and medical consent forms as required by 102417(g)(7) were lost or destroyed. This poses a potential risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Wynn Norona
LICENSING EVALUATOR NAME:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2021


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Document Has Been Signed on 07/28/2021 11:21 AM - It Cannot Be Edited


Created By: Jonathan Williams On 07/28/2021 at 10:22 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: SU, NANCY
FACILITY NUMBER: 013419798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2021
Section Cited
CCR
102417(g)(8)

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(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
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Licensee shall submit completed roster of children to LPA by the POC due date.
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This requirement was not met as evidenced by: Based on Licensee statement, no roster has been created. This poses a potential risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type B
08/04/2021
Section Cited
HSC1596.8662(b)(1)

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training...
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Licensee shall complete the Mandated Reporter trainings "General" and "Child Care Providers" and submit certificates of completion to LPA by the POC due date.
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This requirement was not met as evidenced by: Based on LPA observation, Licensee did not complete the required Mandated Reporter training courses. This poses a potential risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Wynn Norona
LICENSING EVALUATOR NAME:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2021 11:21 AM - It Cannot Be Edited


Created By: Jonathan Williams On 07/28/2021 at 11:04 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: SU, NANCY
FACILITY NUMBER: 013419798

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2021
Section Cited
CCR
102417(g)

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(g) The home shall be free from defects or conditions which might endanger a child. This requirement was not met as evidenced by:
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Licensee shall remove the broken wood beams from the on-limit area of the backyard.
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Based on LPA observation, there were broken wood beams accessible to children in the on-limits area of the backyard. This poses a potential risk to the health and safety of children in care.
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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:Wynn Norona
LICENSING EVALUATOR NAME:Jonathan Williams
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2021


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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: SU, NANCY
FACILITY NUMBER: 013419798
VISIT DATE: 07/28/2021
NARRATIVE
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The facility has a fully charged 2A10BC fire extinguisher, working smoke detector/carbon monoxide detector (both tested at 8:55am), and working telephone. Licensee has current CPR/1st Aid training which expires on 4/10/2023. The facility is in ratio today. Children's files were reviewed for proper documentation.

Incidental Medical Services (IMS) policy was discussed. This facility does not provide IMS at this time. 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.”

Licensee was reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident.
Licensee was reminded that California Law requires licensed Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624b). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the Licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the Licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

There are deficiencies cited, including one type A deficiency. This report shall remain on file for 3 years. A Notice of Site Visit was provided to the Licensee. LPA reminded the Licensee to post the Notice of Site Visit where it is clearly visible inside the facility for 30 days. Appeal rights were provided to the Licensee and the signature on this form acknowledges receipt of these rights. Exit interview was conducted.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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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: SU, NANCY
FACILITY NUMBER: 013419798
VISIT DATE: 07/28/2021
NARRATIVE
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One Type A deficiency was cited today and must be corrected by the due date. Upon receipt, Director shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgment form of proof of receiving this report (LIC9224). The LIC 9224 must be placed in each child's file to be reviewed by a licensing representative upon request.

Exit interview conducted.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC809 (FAS) - (06/04)
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