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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420595
Report Date: 03/11/2022
Date Signed: 03/11/2022 12:08:17 PM

Document Has Been Signed on 03/11/2022 12:08 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:MISSION SAN JOSE CHILDREN'S HOUSEFACILITY NUMBER:
013420595
ADMINISTRATOR:CHIH MEI CHUOFACILITY TYPE:
850
ADDRESS:40065 MISSION BLVDTELEPHONE:
(510) 668-1277
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY: 45TOTAL ENROLLED CHILDREN: 45CENSUS: 11DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:41 AM
MET WITH:Chih Mei ChuoTIME COMPLETED:
12:15 PM
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On 03/11/2022, Licensing Program Analyst (LPA) Melanie Otsuji conducted an UNANNOUNCED REQUIRED 1-YEAR INSPECTION. LPA met with Director, Chih Mei Chuo. Also present during today's visit was an additional staff member and 11 preschool aged children. On today's date, the facility is within ratio and capacity. The facility currently operates 7:00am - 7:00pm, Monday - Friday in 2 classrooms. The facility was toured to conduct a Health and Safety inspection.

Classrooms: All classrooms were inspected for age-appropriate furnishings, equipment, & adequate storage for children’s belongings. LPA observed the cleanliness of floors & surfaces, the presence of a fully functional carbon monoxide detector, smoke detector/fire alarms, and a fully charged fire extinguisher that is accessible throughout the facility. The center is equipped with a fully stocked first-aid kit and available in the classrooms.Food Service Areas: Facility has a full kitchen with a stove, sink, microwave and refrigerator. No cleaners were found stored with food items. Currently children bring snacks and lunch from home. Facility has back up food should a child forget. Bathrooms: Facility has separate staff and child designated bathrooms. Toilets and faucets are in safe and sanitary operating condition. The children are able to reach the sinks and toilets. Supplies are available to children. Outdoor Play Area: There are no bodies of water, or free-standing water accessible to children. There are age appropriate toys and materials for the children. The playground outside is fenced and all equipment and surfaces are free from hazards. Records: All individuals subject to criminal record review have a clearance and have been associated to the facility. LPA reviewed 10 children’s files and 2 staff files around 9:30am. LPA reviewed the facility roster & personnel record and obtained a copy. At least one opening/closing staff member has a current Pediatric CPR/First-Aid Certification. Mandated Reporter certificates were reviewed. Qualified Teacher's CPR/First-Aid Certificate is current and expires on 9/11/2023. The center is in compliance with sign in and out procedure. Emergency Drills are recorded and performed at least every six months. Per facility representative, there are no firearms on the premises. All required documents are posted in a publicly accessible area.

***Continued on LIC 809C***

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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: MISSION SAN JOSE CHILDREN'S HOUSE
FACILITY NUMBER: 013420595
VISIT DATE: 03/11/2022
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Health-Related Services: This facility plans to provide Incidental Medical Services. For IMS information see Evaluator Manual – Regulation Interpretations & Procedures for Child Care Centers sections 101173 & 101226. 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

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.

Director was reminded that all adults 18 and over, 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 Child Care Center. 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.

No citations were found on today's date. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the Director, Chih Mei Chuo.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
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