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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700221
Report Date: 07/16/2024
Date Signed: 07/16/2024 01:08:32 PM

Document Has Been Signed on 07/16/2024 01:08 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 SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:LI, FENG JUANFACILITY NUMBER:
015700221
ADMINISTRATOR/
DIRECTOR:		LI, FENG JUANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 601-7354
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
07/16/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Feng Jun LiTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 7/16/2024 at 10:15AM Licensing Program Analyst (LPA) Jaleesa Jackson met with Licensee Feng Juan Li for an Annual/Random visit. Present during the inspection was the Licensee, her husband, her fingerprint cleared assistant (Licensee's mother), Licensee's fingerprint cleared brother, Licensee’s 4 year old son and 2 preschool aged children, and 3 infants. Licensee lives in the home with her husband, their minor son, her parents and brother. Licensee’s home was toured for a health and safety inspection. The facility operates from 8:00AM – 5:30PM, Monday - Friday.

ON LIMITS AREA: Family Room, 1st Bedroom on the left (napping room), Dining Room (Added as of today's visit), Hallway Bathroom and right side of the Backyard

OFF LIMITS AREA: Living Room, Kitchen, 2nd Bedroom on the left, Master Bedroom and Bathroom, Garage, left side of Backyard

ISOLATION AREA: Nap Room

The facility is a single-story home owned by the Licensee. The inside of the home was observed to have age-appropriate materials for the children. During today's inspection all toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. At 11:30AM, LPA observed 5 children having their lunch in feeding chairs in the OFF LIMITS dining room. LPA asked Licensee if she would like the room to be ON LIMITS. Licensee stated they used the area only sometimes. LPA informed Licensee that rooms that are OFF LIMITS need to be approved by Licensing prior to use. LPA approved the previously OFF LIMITS room to ON LIMITS on today's visit. Licensee provides all food for the children. All food that is brought from the children’s home will be properly labeled and stored. Licensee stated that they do not transport children. There are no pets and no firearms in the home.
Continued on 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LI, FENG JUAN
FACILITY NUMBER: 015700221
VISIT DATE: 07/16/2024
NARRATIVE
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The home has a fully charged 2A10BC fire extinguisher. The home has a working carbon monoxide detector and smoke alarm. The home is equipped with central heat and air for proper ventilation. LPA observed the napping area, one pack and play had a very loose fitted sheet and the second had a fleece blanket wrapped around it in place of a fitted sheet. LPA reminded Licensee that infant safe sleep requires that all cribs or pack and plays need a tight fitted sheet around the mattress. The fireplace in the family room is blocked making it inaccessible to children in care. The backyard is fully fenced and well maintained with age appropriate materials for the children. There is a fence separating the on and off-limits areas of the backyard. There is also a shed next to the sliding glass door that is used as storage. LPA did not observe any bodies of water in or around the home that could be a potential danger to the children in care.

LPA review 5 children's files and found that 1 was missing the LIC995 (Parental Rights). Licensee’s Pediatric CPR and First Aid training's have been completed and expire 2/2025. Licensee’s Mandated Reporter training is complete and expires 6/4/2026. All adults living in the home have obtained a criminal record clearance. Licensee's brother does not have a proof of Tuberculous test to provide at the time of visit. All required forms are posted and visible for public view in the entry way of the home.

There are 4 deficiencies cited on today's visit. See 809-D for deficiencies.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Continued on 809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2024 01:08 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 07/16/2024 at 12:00 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: LI, FENG JUAN
FACILITY NUMBER: 015700221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 pack and plays do not have the appropriate tight fitted sheet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee will replace both the loose fitted sheet in the one pack and play and the blanket wrapped around the second pack and play mattress with a tight fitted sheets. Licensee will submit proof to LPA by POC date 8/16/2024 by email.
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in providing care to an off limits area without notifying Licensing which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee will submit a statement that they will notify Licensing of any change from off limits to on limits prior to use. Signed and dated statement will be sent to LPA by POC date by email.
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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2024 01:08 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 07/16/2024 at 12:00 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: LI, FENG JUAN
FACILITY NUMBER: 015700221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 5 children were missing the LIC995 in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee will submit the missing LIC995 to the LP by email by POC date.

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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2024 01:08 PM - It Cannot Be Edited


Created By: Jaleesa Jackson On 07/16/2024 at 12:00 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: LI, FENG JUAN
FACILITY NUMBER: 015700221

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102369(b)(9)
Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in Licensee's brother does not have a current TB clearance on file prior to moving in the the Family Child Care Home which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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Licensee will submit an updated LIC279 adding her brother (A1) to the section adults living in the home and submit his current TB clearance that is no more that 1 year old with the application. Application must be mailed or dropped off to the Oakland Regional Office with a wet signature by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jason Jang
LICENSING EVALUATOR NAME:Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024


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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LI, FENG JUAN
FACILITY NUMBER: 015700221
VISIT DATE: 07/16/2024
NARRATIVE
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Feng Juan Li, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Feng Juan Li.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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