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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420448
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:10:10 PM

Document Has Been Signed on 03/21/2024 03:10 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:HE, ZHIFACILITY NUMBER:
013420448
ADMINISTRATOR:HE, ZHIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 290-3827
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 8DATE:
03/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Zhi HeTIME COMPLETED:
03:20 PM
NARRATIVE
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On 3/21/2024, at 1:35PM, Licensing Program Analysts (LPA), B.Crass and A. Curry, arrived at the home for an unannounced case management inspection. LPA met with licensee Zhi He to explain the purpose of todays visit. During the initial complaint visit on 3/19/2024 the licensee indicated she does not currently live in the home. (See 809-D for deficiency cited). Licensee stated she resides in other home in Albany, CA. The licensee was advised to surrender her license, or move back into the home.

Exit interview conducted, appeal rights were given, notice of site visit was given, and report was reviewed with the licensee Zhi He.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Brittany Crass
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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 03/21/2024 03:10 PM - It Cannot Be Edited


Created By: Brittany Crass On 03/21/2024 at 02:41 PM
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HE, ZHI
FACILITY NUMBER: 013420448

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2024
Section Cited
CCR
102417(a)

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(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.
This requirement is not met as evidence by:
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By 3/25/24, the licensee will either surrender her license, or move back into the home. The licensee will email LPA what she plans to do. LPA will make a follow up visit.
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Based on interview, the licensee did not comply with the section cited above by not living in the home.
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Brittany Crass
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
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