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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434407893
Report Date: 02/11/2025
Date Signed: 02/14/2025 03:15:25 PM

Document Has Been Signed on 02/14/2025 03:15 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SIU, LOUISEFACILITY NUMBER:
434407893
ADMINISTRATOR/
DIRECTOR:		SIU, LOUISEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 531-8830
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
02/11/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:LOUISE SIUTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA), Shine Yu, conducted an unannounced Annual Inspection 12:45pm. LPA was greeted with Licensee Louise Siu.

LPA observed the following materials posted on the wall at Patio room, including the Facility License, Notification of Parents' Rights (PUB 393), Emergency Disaster Plan (LIC 610), and Earthquake Preparedness Checklist (LIC 9148). The last fire drill conducted was 11/14/2024. Facility's operating hours are Monday to Friday 8:00 AM to 4:30 PM. LPA acquired a photo of current Children's roster. Present are licensee, 1 helper and 6 children, all children are over 2 years old, and 2 of them are part time.

LPA reviewed a random selection of 6 children's files and observed that notification of parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification forms are in each file. One file missed Parent's signature on LIC 995A form. LPA also reviewed the licensee's pediatric First Aid & CPR expires at Dec, 2025. LPA also reviewed the staff's file which has pediatric First Aid & CPR expires at 11/14/2025 and current Mandated Reporter Training certificate (exp: 08/16/2025).

LPA toured the facility with licensee. There is smoke detector and carbon monoxide detector in the living/dinning room. The fireplace is barricaded and inaccessible to the children. There are age appropriate toys for children. Licensee stated there is no firearm in the facility. There is no body of water observed outside of play yard. The outdoor play area is enclosed with appropriate fence and safe for children.

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.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SIU, LOUISE
FACILITY NUMBER: 434407893
VISIT DATE: 02/11/2025
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.

Licensee stated there is one child whose parent keeps EpiPen in the facility. This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/. LPA provided a copy of UCSF IMS in Child Care Programs to Licensee.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

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

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.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SIU, LOUISE
FACILITY NUMBER: 434407893
VISIT DATE: 02/11/2025
NARRATIVE
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Exit interview conducted and report was reviewed with licensee, Louise Siu.

the licensee also 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.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/14/2025 03:15 PM - It Cannot Be Edited


Created By: Syhshyan Yu On 02/11/2025 at 03:55 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SIU, LOUISE
FACILITY NUMBER: 434407893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025

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 one out of 6 children file records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2025
Plan of Correction
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Licensee will have parent sign the LIC 995A form when pick up the child. Licensee will submit POC to LPA before due date, to assure comply with the above regulation in the future.

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:Gladys Kuizon
LICENSING EVALUATOR NAME:Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025


LIC809 (FAS) - (06/04)
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