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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013417860
Report Date: 01/06/2021
Date Signed: 01/06/2021 09:52:00 AM

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) 827-2880
CITY:CASTRO VALLEYSTATE: CAZIP CODE:
94546
CAPACITY:14CENSUS: 0DATE:
01/06/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Eva Qi Hua LiTIME COMPLETED:
10:00 AM
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On 01/06/21 at 9:00am, Licensing Program Analyst (LPA) B.Plumboy conduct an Announced Case Management initiated by licensee by virtual Tele Visit inspection. This inspection was via Facetime for the purpose of changing the on and off limit areas. LPA Plumboy and Licensee Eva Qi Hua Li toured the home due to the licensee renovating her home and making changes to the floorplan. A new floorplan was submitted to LPA Plumboy on 1/2/21. Licensee walked through her home with LPA Plumboy with Facetime video due to the COVID-19 pandemic. Present during today's visit was the licensee's son Andrew Liu, and licensee's husband Jim Liu. The facility currently operates Monday through Friday from 7:30am until 6:00pm.

ON LIMIT AREAS are: the living room, the bedroom located on the right side of the hallway, and the hallway bathroom.

OFF LIMIT AREAS are: the bedroom on left side of the hallway, the kitchen, the master bedroom with master bathroom located off the kitchen, and the garage.

The ISOLATION AREA will be the bedroom located on the right side of the hallway. 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.

As of 1/6/21, the licensee's backyard is off limits to children in care.

This report shall remain on file for 3 years. A notice of site visit was emailed and must remain posted for 30 days. Exit interview conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021
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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