013419798-7-21-2023-52-CC-MPRE-CTXPUK-20230721113740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013419798
Report Date: 07/21/2023
Date Signed: 07/21/2023 11:37:48 AM

Document Has Been Signed on 07/21/2023 11:37 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, NANCY		FACILITY NUMBER:	013419798
ADMINISTRATOR:	SU, NANCY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 668-0312
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 3	CENSUS: 2	DATE:	07/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Nancy Su		TIME COMPLETED:	11:36 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 7/21/2023 at 9:55am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Nancy Su for a Required – 1 Year Inspection. Present during the inspection was the Licensee and two (2) infants. The facility operates 9:00am – 6:00pm, Monday - Friday. ON LIMITS AREA: Living Room (Childcare Area), Dining Area (Childcare Area), Kitchen, Hallway Bathroom, Bedroom on opposite side of Kitchen (Used for Sleeping) and Right side of Backyard OFF LIMITS AREA: Master Bedroom and Bathroom, Two (2) Bedrooms, Garage and Remainder of Backyard ISOLATION AREA: Bedroom or Dining Area The facility is a single-story home owned by the Licensee. The inside of the home is observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, personal medications, and hazardous materials were observed to be in inaccessible areas. All off-limit areas were made inaccessible with gates, locks, and closed doors. Licensee has stated that there are no firearms and no pets in the home. The home has one (1) fully charged 2A10BC fire extinguisher on the wall next to the garage door. There is one (1) working smoke detector in the in the living room, the bedroom and in the hallway next to the bathroom. There is a working carbon monoxide detector on the ceiling in the living room. The home is equipped with central heat and air for proper ventilation. Licensee provides snacks for the children and lunch is brought from the children's home. All food that is brought from the children’s home will be properly labeled and stored. All play yards used for infant sleeping are clean, and free from defects. All other napping equipment is properly stored and well maintained. Licensee stated she does not transport children.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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: SU, NANCY	FACILITY NUMBER: 013419798
	VISIT DATE: 07/21/2023

NARRATIVE

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The back yard is fully fenced, clean and well maintained. There is an empty in ground swimming pool in the far-left corner of the backyard that is gated off and locked making it inaccessible to the children in care. Licensee stated that the swimming pool has been empty and not in use for years. There is also a sand box that is currently not in use and will remain completely covered until she can find a way to protect it from the neighborhood cats.

Facility is operating within its licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed and Pediatric CPR and First Aid training is complete and expires 4/22/2025. Licensee’s Mandated Reporter training is complete and expires 7/31/2023. All required forms are posted and visible for public view in the entry way of the home. Facilities fire drill log is complete with the last drill logged 2/8/2023. All adults living, working, and/or volunteering in the home have obtained a criminal record clearance. LPA obtained the children’s files, facility files, and facility roster. All files were complete.

No deficiencies were cited during the inspection.

Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or email. Licensee was reminded that any structural changes or additions to the home must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting https://mandatedreporterca.com/. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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: SU, NANCY	FACILITY NUMBER: 013419798
	VISIT DATE: 07/21/2023

NARRATIVE

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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Nancy Su, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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: SU, NANCY	FACILITY NUMBER: 013419798
	VISIT DATE: 07/21/2023

NARRATIVE

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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

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

Exit interview conducted and report was reviewed with the Licensee Nancy Su.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

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