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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700221
Report Date: 07/16/2021
Date Signed: 07/16/2021 10:23:13 AM

Document Has Been Signed on 07/16/2021 10:23 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:LI, FENG JUANFACILITY NUMBER:
015700221
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
07/16/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Feng Juan LiTIME COMPLETED:
10:30 AM
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On Friday, July 16, 2021 at 9:00 AM, Licensing Program Analyst (LPA) Manel Estoesta conducted an announced Pre-Licensing Visit. LPA met with the applicant Feng Juan Li. Present for this visit fingerprinted and criminal record cleared Applicant's spouse, Applicant's parents and Applicant's toddler son. The applicant has submitted a change of location application for Family Child Care Home Small License. The applicant's previous license number was 384003786. The applicant hours of operation will be from Monday to Friday 8 AM to 5 PM.

LPA toured the home to conduct a Health and Safety inspection. The home is a single story three (3) bedroom and two (2) bathroom home. The home is neat and clean with central heating and ventilation for safety and comfort. The home does not have a fireplace. The applicant owns the home and submitted a proof of property ownership.

The On Limits area are one of the bedroom for napping, hallway bathroom, indoor children playroom and outdoor children yard. The indoor children playroom has a gate facing the dining area. The backyard will be a designated outdoor play area that is fully fenced. The indoor and outdoor children area have an age appropriate toys and learning materials that appear to be clean and free from defects and dangerous conditions. There are no pools, hot tubs or any other bodies of water. The designated isolation area will be the living room. All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged fire extinguisher 2A10BC, working smoke detector, telephone (mobile phone) and fully stocked first aid kit. Per applicant, there are no firearms on the premises.

The Off Limits area are the (two) 2 remaining bedroom, one (1) bathroom, kitchen, living room, dining room, garage, side yards and the other side of the backyard and will be inaccessible to children by locked doors,and or safety gates.

The applicant do not have a carbon monoxide installed on the time of the inspection.

SEE 809 C....

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: LI, FENG JUAN
FACILITY NUMBER: 015700221
VISIT DATE: 07/16/2021
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Continuation........

The applicant completed the Health and Safety training and CPR (Pediatric) and First Aid is certified and current. A packet of forms pertaining to the children’s files and facility files were reviewed and discussed. The applicant has proof of immunization and has completed the mandated reporter training.

Individual Medical Services (IMS) policy was discussed. 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



Applicant 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.

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.

SEE 809 C.......

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: LI, FENG JUAN
FACILITY NUMBER: 015700221
VISIT DATE: 07/16/2021
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Continuation.....

Missing requirement on the time of the inspection;

1. Installation of Carbon Monoxide.

The applicant will but and install a Carbon Monoxide, will send a photo to LPA together with a video showing the Carbon Monoxide is working.

This home is not recommended for licensing on the time of this inspection. Advised the applicant, license will be granted after the submission of the remaining requirement.

This report shall remain on file for 3 years. Exit interview conducted

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3