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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419798
Report Date: 05/13/2022
Date Signed: 05/13/2022 11:11:19 AM

Document Has Been Signed on 05/13/2022 11:11 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: 2CENSUS: 0DATE:
05/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Nancy SuTIME COMPLETED:
11:20 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 05/13/2022 approximately at 8:50AM Licensing Program Analyst (LPA) Kelly Phan arrived at for an unannounced required inspection, and met with Licensee Nancy Su. For this inspection was the licensee, no children were present. Also residing in the home is the licensee's fingerprinted and associated husband. The Licensee has adult children but do not reside in the home. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 9:00am to 6:00pm.

ON LIMITS: kitchen, hallway bathroom, fenced backyard, living room (main daycare room), bedroom across from the kitchen (used for infants).
OFF LIMITS: garage, all bedrooms, master bathroom, and both side yards. Off limit areas are inaccessible by closed and/or locked doors, gates, and full visual supervision.

The home is single story, which is neat and clean, with heating and ventilation for safety and comfort. A door is being used to keep children in the main day-care room area and prevent any access to OFF limit area such as the bedrooms .There were ample age appropriate toys and activities that were observed to be safe and in good condition. There were a fully charged 2A10BC fire extinguisher, working carbon monoxide, smoke detectors, and telephone. Per licensee there is no fireplace, firearms, or pets or any bodies of water in the home. At 9:00AM, LPA toured all the ON limit areas and found that there were no toxins or anything hazardous accessible to children. LPA informs licensee to store away the diaper rash ointments in the sleeping infant room despite no children will be using it; licensee immediately store it in the bedroom closet observed by LPA. At 9:10AM, LPA also toured the backyard area and observed an empty swimming pool on the premises, however per licensee, it has never been used and is fenced and gated so no children is able to access it. LPA verified with licensee that she is does not have any documentation of a fire drill log; LPA suggests licensee to conduct and document a fire drill log and send it to LPA by 05/20/2022
SEE LIC 809 C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE: DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2022
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 5
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: 05/13/2022
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
At 9:25AM, LPA observed that the licensee only had her license posted; LPA explains and given all required licensing documents such as PUB 394 (Notification of Family Rights) and LIC 610A (Emergency Disaster form) to licensee to be posted. Licensee states that she was never instructed to have documents posted for public review, only given to families. LPA observed that the facility has liability insurance from 02/22/2022 until 02/24/2023 on file; no LIC 282 forms were needed.

At 10:00am, 2 children's files were reviewed and found to be complete. However, LPA informs licensee all children's shot records will have to be documented on the blue immunization card unless they are school aged and attending school. Licensee understood. LPA also confirmed with licensee that she does not have a current facility roster; she states she only caring for two children; LPA still insists licensee to have a current roster on hand. Type B deficiency was cited. SEE LIC 809D. Licensee also did not have any proof of the required immunization nor required mandated reporter training. LPA suggests licensee to send corrections via text, email, or mail by 05/30/2022. CPR and First Aid training are valid as of 04/10/2023.

There were two deficiencies were cited for today's inspection:
At 10:00AM, LPA also confirmed with licensee that she does not have a facility roster; she states she only caring for two children; LPA still insists licensee to have a current roster on hand. Type B deficiency was cited. SEE LIC 809D. Also during record review, LPA observed and confirmed with licensee that she does not have any proof of the required immunization. SEE LIC 809D.

Appeal rights and a notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00. Exit interview conducted and report was reviewed with licensee Nancy Su.

SEE LIC 809 C



SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/13/2022 11:11 AM - It Cannot Be Edited


Created By: Kelly Phan On 05/13/2022 at 10:24 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: 05/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above as licensee failed to maintain required immunizations at her facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
1
2
3
4
Licensee would call her health provider for an appointment to obtain health records
Licensee would send proor to LPA by 05/30/2022
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above as licensee failed to maintain a current facility roster to review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2022
Plan of Correction
1
2
3
4
Licensee would comply her facility roster and send to LPA by 05/30/2022
LPA Phan also given a copy of facility roster to licensee to use
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:Jason Jang
LICENSING EVALUATOR NAME:Kelly Phan
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
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: 05/13/2022
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
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.


Incidental Medical Services (IMS) policy was discussed. This facility provides IMS to children in care. The facility is following and have developed IMS plan on file. When any changes to the IMS plan is made, an updated 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.”

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.


SEE LIC 809 C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 05/13/2022
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 California Law requires licensed Child Care Centers 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 Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. 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.

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/process.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5