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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416413
Report Date: 12/01/2022
Date Signed: 12/01/2022 11:55:21 AM

Document Has Been Signed on 12/01/2022 11:55 AM - 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:HSAW, JASPERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 224-2380
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 14TOTAL ENROLLED CHILDREN: 9CENSUS: 7DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Jasper HsawTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA), Marilou Monico, met with Licensee, Jasper Hsaw, and conducted an unannounced Required - 1 Year Inspection. Also present in the home were licensee's spouse, licensee's adult daughter, and seven (7) daycare children including three (3) infants and four (4) preschool age. LPA toured the indoor and outdoor areas of the home. LPA observed all the required posted materials. Days and hours of operation for the facility are Monday – Friday, 8:30 AM- 6:30 PM. There are no active waivers or exceptions for this facility. Licensee states that there are four adults residing in the home: himself, his spouse, his daughter, and a tenant.

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 violated.

LPA reviewed and obtained copy of facility roster (LIC9040). Fire/disaster drill was conducted on September 2, 2022. LPA observed a fully charged 3A40BC fire extinguisher, barricaded fireplace, gated kitchen, barricaded stairs, and functioning smoke and carbon monoxide detectors. Licensee states that he does not have any children in care who require Incidental Medical Services and does not administer medication at this time. Licensee states that there are no weapons or firearms in the home.

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 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
Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2022
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HSAW, JASPER
FACILITY NUMBER: 434416413
VISIT DATE: 12/01/2022
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LPA observed that the home is clean, orderly, and safe for the day care children. Off limit areas inside the home: entire upstairs, kitchen, laundry room, and garage. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture such as tables, couch, chairs, and shelves are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via sippy cups and individual water bottles. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (650) 224-2380.

The outdoor licensed areas of the home were inspected and observed to be fenced in. Off limit areas outside the home: locked storage shed. There were no bodies of water observed.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page 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 he registers all infant devices with the CPSC to be notified of any recalls on his purchased equipment.

Nine (9) children’s files were reviewed during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC 627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), Individual Infant Sleeping Plan (LIC 9227), and Immunization Records. Child #3 is missing LIC 9227 in the file.

Two (2) helper's files were reviewed for the following records: Criminal Record Statement (LIC 508), Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunization in measles, pertussis, and flu, and required training. Licensee has immunization in measles, pertussis, and flu. The Licensee has Mandated Reporter Training that expires on June 17, 2023. Licensee's CPR/First-Aid expires on May 9, 2024. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.

Continuation on next page:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HSAW, JASPER
FACILITY NUMBER: 434416413
VISIT DATE: 12/01/2022
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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process


Exit interview conducted and report was reviewed with the Licensee, Jasper Hsaw.

As a result of today's inspection, deficiency was cited on the following page:

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
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Document Has Been Signed on 12/01/2022 11:55 AM - It Cannot Be Edited


Created By: Marilou Monico On 12/01/2022 at 11:16 AM
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: HSAW, JASPER
FACILITY NUMBER: 434416413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, Child #3 is missing the Individual Infant Sleeping Plan (LIC 9227) in the file. This poses a potential risk to the health, safety or personal rights to children in care.
POC Due Date: 12/12/2022
Plan of Correction
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Licensee states he will submit a completed and signed LIC 9227 for Child #3 by 12/12/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022


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