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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700016
Report Date: 09/07/2023
Date Signed: 09/07/2023 09:51:26 AM

Document Has Been Signed on 09/07/2023 09:51 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:CHAN, AI YIFACILITY NUMBER:
015700016
ADMINISTRATOR:CHAN, AI YIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 220-7032
CITY:SAN LORENZOSTATE: CAZIP CODE:
94580
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
09/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Ai Yi ChanTIME COMPLETED:
10:08 AM
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***Please note an inspection was done back in Feb 2023, but FAS is indicating to do an inspection this month.

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. 3 infants and 6 preschool age children (9 children total) along with her fingerprint cleared assistant: Inaly Yab.


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 hallway, 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. 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 2025. Per licensee, there are no firearms in the home. The licensee's mandated reporter training is current and expires (November 2023). The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on August 2023. 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
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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