<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419798
Report Date: 08/04/2021
Date Signed: 08/04/2021 10:47:22 AM

Document Has Been Signed on 08/04/2021 10:47 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:
08/04/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Nancy SuTIME COMPLETED:
11:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/4/2021 at 09:15am, Licensing Program Analyst (LPA) Jonathan Williams met with Licensee (Nancy Su) for an unannounced Plan of Correction visit. Present for today's inspection was the Licensee and three children in care. Visit was conducted with the assistance of a Mandarin translator at the request of Licensee.

At 9:20am, LPA Williams observed child locks preventing access to detergents and cleaning compounds. Deficiency cleared.

At 9:23am, LPA Williams observed broken wood beams to be removed from the backyard. Deficiency is cleared.

At 9:26am, LPA Williams observed LIC627 and LIC700 in each child's file as well as children's roster. Deficiencies cleared.

At 9:31am, LPA Williams observed Mandated Reporter trainings for "General' and "Child Care Providers for Licensee which expire on 7/31/2023. Deficiency cleared.

At 9:34am, LPA Williams observed the Licensee and three children in care to be the only individuals in the facility. LPA confirmed Licensee's son to not be present in the facility. Type A deficiency is cleared.

At 9:40am, LPA Williams explained Appeal Rights to Licensee in-depth with the assistance of Mandarin translator. Appeal process was clarified and LPA answered Licensee's questions about the appeal process. Licensee understands how to file an appeal.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 08/04/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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 624). 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 no deficiencies cited. 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. Exit interview was conducted.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jonathan Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2