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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416413
Report Date: 09/15/2021
Date Signed: 09/15/2021 03:10:38 PM

Document Has Been Signed on 09/15/2021 03:10 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:HSAW, JASPERFACILITY NUMBER:
434416413
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:03 PM
MET WITH:Jasper HsawTIME COMPLETED:
03:20 PM
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#2 Licensing Program Analyst (LPA), Marilou Monico, met with Licensee, Jasper Hsaw, and conducted an unannounced Required- 1 Year inspection and in response to Licensee's request to increase the capacity from 8 to 14 children. Licensee's wife and four daycare infants were also present. There are four (4) adults residing in the home: licensee, licensee's wife, licensee's daughter, and a renter. The home is a two storey: 4 bedrooms and three bathrooms. The daycare is open Monday to Friday from 8:30 AM to 6:30 PM.

LPA toured the home inside and out with the Licensee. Off limit areas in the home: entire upstairs, kitchen, dining room, family room, laundry room, and garage. Off limit areas outside the home: locked storage shed. LPA observed sufficient toys and play equipment for the day care children. Bathroom used by children was observed to be clean and in good condition. There were no bodies of water observed. Licensee states that there are no weapons in the home. LPA observed a fully charged 3A40BC fire extinguisher, functioning carbon monoxide detector, working smoke detector, barricaded stairs, glass covered fireplace, and fenced backyard. Cleaning compounds, sharp objects, and other similar items were stored inaccessible to children.

LPA discussed with Licensee Assembly Bill (AB) 1207 (Mandated Child Abuse Reporter Training) which is required training that began on January 1, 2018 and requires renewal every two years. Mandated Reported Training can be accessed at www.mandatedreporterca.com . Licensee's Mandated Reporter Training (AB1207) expires on June 17, 2023. AB 633 was also discussed with Licensee. Licensee and his wife have current Pediatric CPR/1st Aid certifications with an expiration date of June 2022.

LPA reviewed four (4) children's files. Copy of children's roster was obtained. Fire drill was last conducted on May 6, 2021.

Continuation on next page:
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2021
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: HSAW, JASPER
FACILITY NUMBER: 434416413
VISIT DATE: 09/15/2021
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A review of staff records during today's inspection indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA reminded 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.

LPA reviewed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.
LPA reviewed and provided licensee the following:
1) Safe Sleep Regulations (PIN 20-24-CCP)
2) Ratio/capacity chart

Incidental Medical Services (IMS) policy was discussed. Licensee stated that he is not planning to provide IMS at this time.

Fire clearance was granted on August 24, 2021.

As a result of this inspection, there were no deficiencies cited and a license for a large Family Child Care Home is approved effective today, September 15, 2021.



A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
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