<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416361
Report Date: 02/01/2022
Date Signed: 02/02/2022 03:38:08 PM

Document Has Been Signed on 02/02/2022 03:38 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:AN, NAFACILITY NUMBER:
434416361
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
02/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Na AnTIME COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Anna Morales met with APPLICANT Na An for a PRE LICENSING visit. Applicant is relocating from 101 Ontario Street, San Mateo, CA.
(414004098). Days and hours of operation will be Monday to Friday 8:30am to 6:00PM. The Applicant informed LPA that she and another adult, Ming Jiang are the only adults residing during today's inspection. Applicant and all Adults has subject to a criminal record review have obtained a criminal record and child abuse index clearances prior to today's visit.

The Applicant has completed the Preventative Health Practices course on 1/13/2015 and 1/22/2022 to complete the one hour lead requirement . Applicant has completed the Pediatric First Aid & CPR on 5/2021. Mandated Reporter Training is being waived as English is not her primary language . Proof of completion for these certifications are on file. The Applicant's copies of immunization records are also on file.

The Applicant states that she will have liability insurance and understands that if liability insurance is not carried, she will have the parents complete the Affidavit Regarding Liability Insurance(LIC 9182). The Applicant states that she does not transport children, but understands that children cannot be left in parked vehicles unattended at an time.

The facility is a two story home. LPA observed the main area of the home to be used for the day care will be in two rooms on the first floor, one bathroom, backyard, and dining room. Upstairs there are four bedrooms, two bathrooms which will be off limits. There is a barricade in front of the stairs. Also off limits, is the kitchen, garage and part of the left side of the backyard. In the living room, there is a fireplace which as a screen to prevent access. The children have access to the backyard which is enclosed by a fence. The Applicant has a designated area in the home where a child(ren) can be isolated if exhibiting signs of illness. LPA observed the home is clean and orderly.

(Page 1)
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AN, NA
FACILITY NUMBER: 434416361
VISIT DATE: 02/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Applicant stated that she will have the parents sign in/out on the right side of the house and will take daily temperatures of the children in care. LPA observed the home has working smoke/carbon monoxide detectors on the upstairs ceiling. Applicant stated that she will place another smoke detector/.carbon monoxide detector in the downstairs area. LPA observed a fully charged fire extinguisher.

The Applicant states that she does not smoke and understands that smoking is prohibited during day care hours. The Applicant states that she does not have any baby walkers/inclined sleepers in the home and understands that baby walkers/inclined sleepers are not allowed in the day care. The Applicant states that she does not have any baby bouncers, jumpers, saucer chairs, and trampoline in the home and was advised that they are not allowed in the day care.

LPA observed the kitchen which is not accessible to the children. There are no sharp utensils, lighter/matches or open bottles of alcohol accessible to children. The Applicant understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

LPA observed the activity room with appropriate age activities. All of the detergents or cleaning compounds, sharps, medicines or other items which could pose a danger if readily available to children were stored where they are inaccessible, out of reach of children. LPA reminded Applicant that poisons need to be locked up. No bodies of water observed. The Applicant states that there are no firearms in the home. The Applicant has a first aid kit in the home, which also has a thermometer and sufficient emergency supplies. The Applicant has a working telephone.

Forms of discipline used by Applicant: redirecting and talking. The Applicant understands that children's personal rights should not be violated, including no corporal punishment. Supervision of children, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, lead poisoning prevention, and requirements for assistant/substitute were also discussed with the Applicant during today's inspection.



(page 2)
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AN, NA
FACILITY NUMBER: 434416361
VISIT DATE: 02/01/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Applicant is encouraged to visit the Department's website at www.cdss.ca.gov (shortcut: www.ccld.ca.gov) to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of Laws, etc.

Incidental Medical Services (IMS) policy was discussed with the Applicant today and stated that she does not take care of children if they are sick. and does not plan on administering medication to the day care children at this time. 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.

LPA discussed the requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised the Applicant 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. LPA reminded the Applicant 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.

Licensure for Small Family Day Care pending on final review.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3