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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700396
Report Date: 10/11/2022
Date Signed: 10/11/2022 11:36:10 AM

Document Has Been Signed on 10/11/2022 11:36 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:HE, EMILYFACILITY NUMBER:
015700396
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
10/11/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Emily He- LicenseeTIME COMPLETED:
11:40 AM
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On 10/11/22 at 10:48am, Licensing Program Analyst Briana Plumboy met with licensee Emily He for an ANNOUNCED CHANGE IN LOCATION INSPECTION. Present for this visit was licensees minor age child and mother in law Xianxiao Ng. The home was toured to conduct a Health and Safety Inspection. This facility plans to operate 7 days a weeks, 24 hours per day. The licensee is aware children in care may not stay in care for over 23 hours.

The home is single story. IN the back of the home there is another residence and both homes share the yard. Licensee is aware at no time shall the children in care be in direct, unsupervised contact with the tenants or guest at 3816 Seven Hills Rd. The home consists of a living room, kitchen, dining room,2 bedrooms, 1 master bedroom/master bathroom, and hallway bathroom. The home is neat and clean with heating and ventilation for safety and comfort. The OFF LIMIT AREAS are all bedrooms, dining room, master bedroom/ master bathroom, and kitchen which will be inaccessible by closed and/or locked doors and visual supervision. The ON LIMIT AREAS are the living room, hallway bathroom, and backyard cement area located outside the dining room. The children in care will walk through the dining area with supervision at all times to access the play area in the backyard. The ISOLATION AREA will be the living room. Per licensee the wooden patio and upper deck part of the backyard will be off limits to children in care. Outdoor play area is fenced. There are toys and learning activities. There are no pools, hot tubs or any other bodies of water on the premises.
The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The licensees’s Health and Safety training is completed and CPR and First Aid certificate is current. The licensee completed and received a certificate in mandated reporter training. The licensee is in compliance with new immunization law which pertains to day care providers. The home has centralized
See 809-C for continuance
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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: HE, EMILY
FACILITY NUMBER: 015700396
VISIT DATE: 10/11/2022
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heating and the fireplace in the living room is electrical and screened. Per licensee, there are no firearms in the home. A copy of the deed was reviewed and shows control of property.
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.

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.

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list



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

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



This home is recommended for licensing on 10/11/22. This report shall remain on file for 3 years. Exit interview conducted.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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