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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700316
Report Date: 06/03/2021
Date Signed: 06/03/2021 01:51:00 PM

Document Has Been Signed on 06/03/2021 01:51 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:GU, YUANYUANFACILITY NUMBER:
435700316
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
06/03/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Yuanyuan GuTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) James Sampair conducted a post licensing visit 06/03/21 from 10:00 AM to 12:30 PM with Licensee Yuanyuan Gu. Also present was her underage son and 5 preschool and 1 school-aged children under care. During the visit, the facility was toured inside and outside. There are no firearms in the home and the hot tub was covered and locked.

During the tour of the inside of the facility, the LPA verified that the smoke detectors, the carbon monoxide detector, and the fire extinguisher were fully operational and that they met the State Fire Marshall standards. The LPA also verified that storage areas for poisons were inaccessible to children and locked, and that detergents, cleaning compounds, medications, and other items which could pose a danger to children were stored where they were inaccessible to children.

Further, the home was kept clean and orderly, with heating and ventilation for safety and comfort. On the outside of the home, the stairs were barricaded and both inside and outside of the home safe toys, play equipment, and materials were provided for the children. The Licensee has a working telephone service and she was fully engaged and attentive to the needs of the children in care. She maintained, in each child's record, a copy of the emergency information card that contained all of the information specified by regulation, and in her facility file she had all of the required documentation.

The Licensee was reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of her responsibility as mandated reporter.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GU, YUANYUAN
FACILITY NUMBER: 435700316
VISIT DATE: 06/03/2021
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Effective August 1, 2003 California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Individual Medical Services (IMS) policy was discussed. Per licensee, no IMS is being provided at this time. The licensee was reminded that when any changes to the IMS plan is made, an updated 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.”

No deficiency was cited during today’s visit.

An exit interview was conducted with the Licensee. The Licensee was provided a copy of her appeal rights and the signature on this form acknowledges receipt of these rights. A Notice of Site visit was posted at the time of inspection and must remain posted for 30 days.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
LIC809 (FAS) - (06/04)
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