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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417860
Report Date: 07/17/2019
Date Signed: 07/17/2019 02:56:58 PM

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:LI, EVA QI HUAFACILITY NUMBER:
013417860
ADMINISTRATOR:LI, EVA QI HUAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 728-0132
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:14CENSUS: 7DATE:
07/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Eva Qi Hua LiTIME COMPLETED:
03:30 PM
NARRATIVE
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On 07/17/19, Licensing Program Analyst Briana Plumboy, met with licensee Eva Qi Hua Li for an UNANNOUNCED RANDOM INSPECTION. Present for this visit was licensees finger print clear husband Jim Liu, fingerprint clear son Andrew Liu, 2 infants, and 5 preschool age children. The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 8:00am until 6:00pm.

The home is two levels. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the living room, the left hallway room, the hallway bathroom, the family room, the bedroom located off of the family room, and the sun room. The OFF LIMIT AREAS are the room on the right side of the hallway, the kitchen, the bathroom located in the room off the family room, and the bedroom located off the kitchen which will be inaccessible by closed and/or locked doors and visual supervision. As of 07/17/19, the dining room and a portion of the backyard are on limits. The ISOLATION AREA will be the family room. The portion of the BACKYARD which is utilized for children in care is located behind the white fenced and located at the far end of the yard. There is a laundry room located inside the sun room which is off limits to children in care and has a gate to prevent access to children during today's inspection. There are toys and learning equipment. There are no pools, hot tubs or any other bodies of water present in the on limit areas during today's inspection.
The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The licensee and her husband Jim Liu both have expired CPR and First Aid certificates, and they are enrolled in a course on 08/10/19. The licensee received a certificate in mandated reporting on 03/30/18. The licensee is in compliance with the provider immunization law. According to the licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 06/02/2019.
The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. See 809-C and 809-D for continuance
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: LI, EVA QI HUA
FACILITY NUMBER: 013417860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2019
Section Cited
CCR
102416.3(a)(2)
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Alteration to Existing Building or Grounds. Prior to any alteration, the licensee shall notify the Department of the proposed addition of a room to the family child care home.
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LPA Plumboy and Licensee discussed the importance of children having care in "on limit" areas only. On or before 07/18/19, licensee stated she will watch the video "Locks and Inaccessibily" on the ccld.ca.gov website and submit a written summary to LPA Plumboy via email.
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This requirement was not met as evidenced by: Based on observation and interview, when LPA Plumboy toured the home, a child were sleeping inside off limit area. USE OF OFF LIMITS AREAS POSES AN IMMEDIATE RISK TO CHILDREN IN CARE.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
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: LI, EVA QI HUA
FACILITY NUMBER: 013417860
VISIT DATE: 07/17/2019
NARRATIVE
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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 (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

LPA Plumboy provided a copy of Safe Sleep in Child Care brochure, a handout "What Does A Safe Sleep Environment Look Like?," and PIN 19-06-CCP to the licensee

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility. Licensee was reminded of Departments inspection authority, with our without any notice.

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 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.

The licensee was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.

Licensee is 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 the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov

See 809-C and 809-D for continuance

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LI, EVA QI HUA
FACILITY NUMBER: 013417860
VISIT DATE: 07/17/2019
NARRATIVE
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For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list

See 809D for deficiency. The attached Type A deficiency is cited today. Upon receipt, licensee shall post for 30 days and provide copies of this licensing report to parent/guardians of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 Acknowledgement of Receipt of Licensing Reports should be signed by guardians and placed in each child’s file. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Appeal rights provided and discussed. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4