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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700016
Report Date: 11/02/2021
Date Signed: 11/02/2021 02:28:35 PM

Document Has Been Signed on 11/02/2021 02:28 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:CHAN, AI YIFACILITY NUMBER:
015700016
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ai Yi ChanTIME COMPLETED:
02:45 PM
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Licensing Program Analyst Sidney Cortez, met with licensee Ai Yi Chan for an UNANNOUNCED ANNUAL RANDOM INSPECTION. Present for this visit was the licensee Ai Yi Chan. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 7:30AM until 6PM, MONDAY-FRIDAY

This is a single story home which consists of 4 bedrooms, 2 bathrooms, living room, dining room, kitchen, family room, attached garage, backyard patio, fully fenced backyard with storage shed, and unfenced front yard. The home is neat and clean with heating and ventilation for safety and comfort.


OFF LIMIT AREAS: Kitchen, bedroom to the right of hallway bathroom, family room, restroom in family room area, both bedrooms next to family room, attached garage, and small storage shed in backyard which will be inaccessible by closed and/or locked doors and visual supervision.
ON LIMIT AREAS: living room which has been converted into a children's classroom/activity room, the dining room, bedroom adjacent to living room, which has been converted into a napping room for children in care, bathroom at end of hall way, backyard and patio.
The ISOLATION AREA will be in the living room. Outdoor play area will be the fully fenced patio/ back yard which is free from defects or dangerous conditions. There are ample age appropriate toys that are safe and appeared to be clean. There are no pools, hot tubs or any other bodies of water on the premises during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible during today's inspection.
The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone.The applicant’s Health and Safety training is completed and CPR and First Aid certificates are current and expire March 2023. The applicant is in compliance with new immunization laws which pertain to day care providers. Per applicant, there are no firearms in the home. A copy of the mortgage statement was reviewed and shows control of property.The licensee's mandated reporter training is current and expires (November 2023). Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on July 13, 2021.2 Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. See 809-C for continuance
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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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: CHAN, AI YI
FACILITY NUMBER: 015700016
VISIT DATE: 11/02/2021
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LPA Cortez provided a copy of Safe Sleep in Child Care brochure, a handout "What Does A Safe Sleep Environment Look Like?," and PIN 19-06-CCP to the licensee


LPA Cortez provided licensee with a copy of the CDSS handout on Effects of Lead Exposure and Never Shake a Baby Brochure (attached PUB 271)




The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility. Licensee was reminded of Departments inspection authority, with our without any notice.California Law requires 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. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.




The licensee was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.




Licensee is 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 of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov




For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list. This entire report has been read to the Licensee by LPA Cortez. The licensee is aware the signature on this report confirm receipt of these documents. LPA asked the licensee if the licensee had any questions pertaining to any aspects including, but not limited to, any part of this report and of the documents given to the licensee, and per licensee, there are no further questions at this time. Licensee is aware at anytime she can reach out to LPA Cortez or CCLD. There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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