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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416413
Report Date: 09/25/2024
Date Signed: 09/25/2024 03:48:36 PM

Document Has Been Signed on 09/25/2024 03:48 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/
DIRECTOR:		HSAW, JASPERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 224-2380
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 10DATE:
09/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Ashley HsawTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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
On September 25, 2024 at 1:02 PM, Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Annual Random inspection. LPA met with Licensee's adult daughter, Ashley Hsaw, and explained to her the nature of today's inspection. An adult helper (S1) and 10 daycare children: 4 infants and 6 preschool age were also present in the home. All required posting materials were posted. The daycare is open Monday thru Friday from 8:30 AM to 6:30 PM. There are no active waivers or exceptions for this facility.

LPA obtained a copy of current children's roster. Fire/disaster drill was completed on May 29, 2024. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide detectors, barricaded stairs, and barricaded fireplace. Ashley 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

Licensee's adult daughter, Ashley, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.
Continuation on next pages:
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 4
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: 09/25/2024
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
Off limit areas inside the home: entire upstairs, kitchen, laundry room, and garage. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. No bodies of water were observed.

LPA reviewed 10 children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), sleep log, Individual Infant Sleeping Plan (LIC 9227), Affidavit Regarding Liability Insurance, and Immunization Records. LPA observed that two (2) infants (C1 & C2) are missing the LIC 9227 in their files.

LPA reviewed a helper's file (S1) and Ashley's file for the following records: Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunizations, TB test, and required training. S1 is missing immunizations in measles and pertussis. Licensee, Jasper Hsaw, has immunizations in measles, pertussis and flu. (S1) has current Pediatric CPR/First Aid certifications. Licensee's Mandated Reporter Training expired on April 24, 2025. LPA reminded Ashley that Mandated Reporter Training must be renewed by all staff every 2 years.

LPA provided and discussed the safe sleep regulations with Ashley discussed the Child Care Licensing Safe Sleep webpage at an additional resource. LPA also reminded Ashley of the importance of checking for recalled infant devices https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as 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.


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

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 09/25/2024
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
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.

Licensee's adult daughter, Ashley Hsaw, was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&R's) throughout California.

As a result of today's inspection, Type B deficiencies were cited.

Exit interview conducted and report was reviewed with Ashley Hsaw, Licensee's adult daughter.

During the exit interview, Licensee's adult daughter, Ashley Hsaw, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/25/2024 03:48 PM - It Cannot Be Edited


Created By: Marilou Monico On 09/25/2024 at 03:11 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: HSAW, JASPER
FACILITY NUMBER: 434416413

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, an adult helper (S1) is missing immunizations in measles and pertussis. This poses a potential health, safety or personal rights risk to persons in care
POC Due Date: 10/16/2024
Plan of Correction
1
2
3
4
By POC Due Date: 10/16/24, proof of S1's immunizaitons in measles and pertussis to be sent to Licensing.
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
1
2
3
4
Based on record review , the licensee did not comply with the section cited above in 2 (C1 & C2) out of 4 infants in care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
1
2
3
4
By POC Due Date: 10/04/24, a completed Individual Sleeping Plan (LIC 9227) for C1 & C2 shall be submitted to Licensing.
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: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4