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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420743
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:26:47 PM


Document Has Been Signed on 07/08/2022 01:26 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:TAN, YUE SHANFACILITY NUMBER:
013420743
ADMINISTRATOR:TAN, YUE SHANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 378-5118
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:14CENSUS: 6DATE:
07/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Yue Shan TanTIME COMPLETED:
01:35 PM
NARRATIVE
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On July 8, 2014 at approximately 9:30 am Licensing Program Analyst (LPA) Haderer arrived unannounced to conduct a 1-year annual inspection for Health and Safety compliance. Present for today’s inspection was the licensee, 2 fingerprint and TB cleared assistants, and adolescent sons and 6 children in care (1, 23 month-old infant; 5 three-years old). The licensee is in ratio today. The hours of operation are Monday through Friday, 8:00am to 5:00pm.

The facility is a single-story home with 4 bedrooms 2 bathrooms, kitchen, living room, (day care area), family room (day care play room) an attached 2-car garage, side and backyard area. Licensee owns the home.

The home is neat and clean with central heating and ventilation for safety and comfort. The outdoor play area is fenced, has a large tarp for shade, and covered with artificial turf for cushioning. The area has a child fence to keep children on the patio area. All fixtures were observed to be free from defects and dangerous conditions. There were ample age appropriate toys inside and outside that were observed to be safe and in good condition. Toxins, medicines, and hazardous items were inaccessible during today's inspection.



ON LIMITS: Living room (day care area), family room (day care area), Bedroom #1 (west side of home) for napping and the attached bathroom, fenced-in backyard area.

OFF LIMITS: Kitchen, Bedrooms 2, 3 and 4 (all on east side of home), main house bathroom, areas outside of fenced in area of backyard (including side yard) and attached 2-car garage. The off-limits areas are inaccessible by closed and/or locked doors, child gates and visual supervision.

There were 3 children in care today that did not have completed files, see LID809D for deficiencies. The child roster was incomplete, see LIC809D for deficiency.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
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 9


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: TAN, YUE SHAN
FACILITY NUMBER: 013420743
VISIT DATE: 07/08/2022
NARRATIVE
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LPA did not observe any bodies of water, hazardous materials, or toxins accessible to children on the premises during the inspection. Disaster drills are conducted every 6 months, the last one was completed on 7-5-2022. The home has a fully charged 3A40BC fire extinguisher stored in the kitchen. There is a working telephone, a smoke detector and carbon monoxide detectors (tested and functioning). The home does not have a fireplace. Per licensee, there are no firearms in the home. Licensee carries liability insurance, policy is in force.

The licensee's Health and Safety training is completed, and CPR and First Aid certificate is current and expires 7/10/2023. The licensee and her helpers completed and received a certificate in Chinese language mandated reporter training (verified AB1207), expire on 7/17/2023. Licensee and one helper is in compliance with the immunization laws which pertains to day care providers.

LPA reminded the licensee of the following; Mandated Reporter training is to be renewed every two years, CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.


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 [or facility representative] 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 [facility representative] 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.

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

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9
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: TAN, YUE SHAN
FACILITY NUMBER: 013420743
VISIT DATE: 07/08/2022
NARRATIVE
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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/inspection-process.

There were 5 deficiencies today due to lack of children’s files and incomplete child roster. See LIC809D for deficiencies. This report will remain on file for 3 years.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Yue Shan Tan.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/08/2022 01:26 PM - It Cannot Be Edited

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: TAN, YUE SHAN
FACILITY NUMBER: 013420743

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 in that Consent for Emergency Medical Treatment form for 3 of 6 children in care was not available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will have all required forms immediately completed by the parents for all children in care.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 in that immunization records for 3 of 6 children in care was not available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will have all required forms immediately completed by the parents for all children in care.

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 CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 07/08/2022 01:26 PM - It Cannot Be Edited

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: TAN, YUE SHAN
FACILITY NUMBER: 013420743

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that a signed receipt of Parents Rights form LIC995A for 3 of 6 children in care was not available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will have all required forms immediately completed by the parents for all children in care.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that the Emergency Information card for 3 of 6 children in care was not available which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will have all required forms immediately completed by the parents for all children in care.

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 CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 07/08/2022 01:26 PM - It Cannot Be Edited

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: TAN, YUE SHAN
FACILITY NUMBER: 013420743

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in that the Child Roster was incomplete and missing 2 of 6 children in care today which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will complete the child roster (and also for those not in care today) and always keep it fully updated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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 CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 6 of 9