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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416361
Report Date: 09/13/2022
Date Signed: 09/13/2022 03:15:20 PM

Document Has Been Signed on 09/13/2022 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-DAY CARE, 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: 6CENSUS: 5DATE:
09/13/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Na AnTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang and Licensing Program Manager (LPM) Gladys Kuizon conducted an unannounced case management visit to the home today. Licensee has requested to increase her licensed capacity to 14 children. Licensee has been licensed as a large Family Child Care Home since April 25, 2016 prior to relocate to this current location on February 3, 2022, and is thus eligible to apply for the capacity increase. LPA met with Licensee Na An and explained the nature of today's visit to her. LPA also observed five day care preschoolers in the home during today's visit. Days and hours of operation are Monday - Friday from 8:30 AM to 6:00 PM. The adults that reside in the home are the Licensee and her business partner. LPA advised Licensee that her two school-age children under age 10 will be accounted to her capacity when present during her operation hours.

A review of staff records on 09/13/2022 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violate

Licensee's certifications for CPR and First Aid are current and on file and expire on 5/2023. Licensee has completed the Preventative Health Practices course on 1/13/2015 and 1/22/2022 to complete the one hour lead requirement. Mandated Reporter Training is being waived as English is not her primary language . Proof of completion for these certifications are on file. Licensee's copies of immunization records are also on file. The facility carries liability insurance under DCI.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AN, NA
FACILITY NUMBER: 434416361
VISIT DATE: 09/13/2022
NARRATIVE
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LPA toured the indoor and outdoor areas of the home during today's visit. 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 (family room, and living room) 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. Licensee has a designated area in the home where a child(ren) can be isolated if exhibiting signs of illness. LPA observed no bodies of water in the facility. The home is clean, orderly, and safe for the day care children. LPA observed a blocked fireplace and no wall heaters.
LPA observed a fully charged 3A40BC fire extinguisher, combined working smoke & carbon monoxide detectors, fenced backyard, and no bodies of water. All detergents, cleaning compounds, medications, and other similar items are stored in the attached garage and in high cabinets inaccessible to the children in care. LPA advised licensee 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. Licensee stated that there are no firearms in the home. The facility has a first aid kit in the home, which also has a thermometer and sufficient emergency supplies.

LPA reviewed the Child Care Facility Roster and Fire/Disaster drill log during today's visit. The last was conducted on 4/29/2022. LPA reminded the Licensee that she needs to keep her roster updated with all current and former day care children. LPA reviewed six children's files and observed immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file, however LIC (627) Consent for Emergency Medical Treatment was missing. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA does not observed any baby walkers/inclined sleepers, nor any baby bouncers, jumpers, saucer chairs, and trampoline in the home and was advised that they are not allowed in the day care.

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 for the large Family Child Care Home license and she also understands that she cannot have more than 14 children in the home at any time with a qualified assistant present.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
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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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: AN, NA
FACILITY NUMBER: 434416361
VISIT DATE: 09/13/2022
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-and-resources/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 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: https://www.ada.gov/childqanda.htm

Licensee was 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.

A deficiency was cited. A notice of site visit was given and must remain posted for 30 days. LPA conducted exit interview and report with Licensee, Na An, and advised her that a large Family Child Care Home license is now pending upon the management approval and the following items:

1. A fire clearance granted inspection report from the San Jose Fire Department was received by the office.
2. Plan of Correction on of the deficiency cited during today's visit received prior to the POC due date.
3. A transfer request for the helper was completed.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2022 03:15 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 09/13/2022 at 02:39 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: AN, NA
FACILITY NUMBER: 434416361

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
1202417(g)(7)

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Operation of a Family Child Care Home: An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
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Licensee agreed to submit the form with the parents signature to the office prior to the POC date.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for missing consent to emergency medical care. which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2022


LIC809 (FAS) - (06/04)
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