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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700016
Report Date: 12/07/2021
Date Signed: 12/07/2021 10:13:55 AM

Document Has Been Signed on 12/07/2021 10:13 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:CHAN, AI YIFACILITY NUMBER:
015700016
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 6CENSUS: DATE:
12/07/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:AI YI CHANTIME COMPLETED:
10:18 AM
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On Dec 7, 2021, Licensing Program Analyst (LPA) Sidney Cortez met with licensee Ai Yi Chan to conduct a case management inspection-licensee initiated, for an increase in capacity. Present during today's visit were four preschool aged children and 2 infants. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 7:30am to 6:00pm.
Fire clearance was granted by Alameda Fire Department on 12/2/2021.

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. 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, the room on the right side has been converted into an activity room, 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 2A10BC 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 03/06/2023. 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. Facility had ample toys and learning equipment. The Licensee's Health and Safety training is completed. The Licensee completed and received a certificate in mandated reporter training and is compliant with required immunizations.
Children's and staff files were reviewed. Updated children's roster was reviewed and a copy obtained. The licensee is in ratio today. See 809 C For Continuation
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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: 12/07/2021
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm.

On 5/18/2021, a fire clearance was granted to this facility by the Fremont Fire Department. All documents have been received for the increase of capacity application. The Licensee was reminded that an assistant is needed with a large family child care home license, and whenever an assistant is not present, the licensee will comply with the capacity requirements for a small family child care home.

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 encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates, and to also email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list.

As of 12/07//2021, this home is recommended for an increase of capacity. The License must be posted for public review in the facility.

There are no deficiencies cited today. Exit interview conducted with Ai Yi Chan. This report shall remain on file for 3 years.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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