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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415419
Report Date: 06/15/2021
Date Signed: 06/15/2021 03:07:21 PM

Document Has Been Signed on 06/15/2021 03:07 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CHENG, ANGELAFACILITY NUMBER:
434415419
ADMINISTRATOR:ANGELA CHENGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 701-7222
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 9DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Angela ChengTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Janette Cruz and Mel Matos met with Angela Cheng, Licensee, for an unannounced Required – 1 year annual inspection. LPAs were granted access to the home by the Licensee. LPAs also observed nine children (3 infants and 6 preschool) and Licensee's mother/adult assistant, Charlene Cheng, in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements during today's inspection. LPAs observed the required postings, including the facility license, near the front entrance to the home. The home has a working telephone (408) 701-7222. Days and hours of operation are Monday - Friday from 9:00AM to 6:00 PM. The Licensee and her spouse, Timothy Hom, are the adults residing in the home. The Licensee's and her mother's CPR and First Aid are current and expire in August 2021.

LPAs reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 06/11/2021. The Licensee, Licensee's spouse, and mother have the required vaccinations (MMR, Tdap, & flu). The Licensee has current Mandated Reporter Training for Child Care Workers on file (exp: 06/09/23). The Licensee's mother is exempted from the Mandated Reporter Training requirement due to language barrier (Mandarin). LPAs reviewed nine children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensee states that a child will be isolated in the front entry way if needed to because of illness or communicable disease.

Safe sleep updated: LPAs discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee.
REPORT CONTINUED ON FOLLOWING PAGE #2 - REPORT DATED 06/15/2021):
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/15/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CHENG, ANGELA
FACILITY NUMBER: 434415419
VISIT DATE: 06/15/2021
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 06/15/2021):
LPAs reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPAs toured the indoor and outdoor areas of the home during today's inspection. LPAs observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. There are no stairs inside the home. There is no fireplace or open face heaters inside the home. Off limit areas inside the home: three bedrooms, one bathroom, family room, kitchen, and attached garage. Off limit areas outside the home: left and right side areas of the backyard.

LPAs observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have any pets and weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Any poisons are locked in the attached garage and inaccessible to the day care children.

A review of staff records on June 16, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPAs also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.
REPORT CONTINUED ON FOLLOWING PAGE #3 - REPORT DATED 06/15/2021):
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CHENG, ANGELA
FACILITY NUMBER: 434415419
VISIT DATE: 06/15/2021
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CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 06/15/2021):
Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time without a fully qualified adult present. The Licensee states that does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

LPAs discussed the requirements of AB 633 with the Licensee and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and the Licensee understands the requirements. LPAs also discussed "zero tolerance" related regulations with the Licensee and advised her of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPAs conducted an exit interview with the Licensee and advised her that no deficiencies issued during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
LIC809 (FAS) - (06/04)
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