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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700316
Report Date: 04/20/2023
Date Signed: 04/20/2023 02:03:48 PM

Document Has Been Signed on 04/20/2023 02:03 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:GU, YUANYUANFACILITY NUMBER:
435700316
ADMINISTRATOR:GU, YUANYUANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(657) 253-9245
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94041
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Yuanyuan GuTIME COMPLETED:
01:15 PM
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On 04/20/2023 at 9:45am Licensing Program Analyst (LPA) Christina Uribe, met with licensee Yuanyuan Gu for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 12 daycare children and 2 assistants (Sophia Garcia Cruz & Christian Orellana) and the licensee is within ratio today. 4 children present are under 2 years of age and 8 children are between 2-4 years of age. Upon arrival LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 9:00am-5:00pm.

The home is a single story home with 1 bedroom, 1 bathroom, living room, kitchen, detached garage and back yard. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort. All on/off-limit areas are consistent with the facility's pre-licensing reports.

The OFF-LIMIT AREAS are the laundry room, & garage and will be inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the living room, bathroom, kitchen, bedroom, and backyard. The living room is the main daycare area and is also used as the isolation area in the corner if needed.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide detector, telephone and fully stocked first aid kit. There is a hot tub in the backyard but there are no pools or any other bodies of water present at the time of the inspection. The hot tub is covered with an appropriately sized cover which is latched closed and can support the weight of an adult. Per licensee, there are no firearms or pets on the premises.

The licensee conducts and documents fire and disaster drills at least twice a year. All required forms are posted and visible for public review.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2023
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GU, YUANYUAN
FACILITY NUMBER: 435700316
VISIT DATE: 04/20/2023
NARRATIVE
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The licensee completed the Health and Safety training, CPR/First Aid certification expires on 01/05/24. The licensee is in compliance with the immunization laws and has completed the mandated reporter training on 12/13/23.

LPA Uribe reviewed 12 children’s files and personnel records. Sleep Charts for sleeping infants were reviewed and within compliance of the Safe Sleep Regulations. There is a current roster available for review and copy obtained. The facility does have liability insurance which is valid through 07/20/23. Staff interview also conducted and documented.



Incidental Medical Services (IMS) policy was discussed and the facility does not have any children with the need for medication to be kept at the facility at this time. 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders, by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email notifications.

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 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.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
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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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: GU, YUANYUAN
FACILITY NUMBER: 435700316
VISIT DATE: 04/20/2023
NARRATIVE
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Effective August 1, 2003 California Law requires Child Care 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 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

Please see attached deficiency and advisory note pages for information on citations issued today:

  • Type A Violation: One assistant present during today's inspection was found to not have an eligible background clearance and is not associated to the facility.
  • Technical Violation: Several children's Identification & Emergency (LIC 700) Forms are incomplete.
  • Technical Violation: Several children's files are missing proof of immunization records.

Due to the licensing agency's zero tolerance policy on uncleared adults living, working, or volunteering at Family Child Care Homes, this results in the issuance of an immediate civil penalty of $500.00.

LPA Uribe informed licensee, Yuanyuan Gu, that this report dated 04/20/2023 documents one (1) Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Uribe informed the licensee to provide a copy of this licensing report dated 04/20/2023 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights were given. Exit interview conducted and report was reviewed with the licensee, Yuanyuan Gu.

Page 3 of 3 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2023 02:03 PM - It Cannot Be Edited


Created By: Christina Uribe On 04/20/2023 at 11:33 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: GU, YUANYUAN
FACILITY NUMBER: 435700316

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one assistant present during today's inspection does not have an eligible criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/20/2023
Plan of Correction
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The uncleared adult left the premises during LPA Uribe's visit to meet compliance. The uncleared adult will not return to the facility until they have obtained an eligible criminal background clearance and has been associated to the facility.
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


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