013421118-6-14-2021-52-CC-BPLY-C3YR8U-20210614124831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421118
Report Date: 06/14/2021
Date Signed: 06/14/2021 12:48:37 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:	NA, NANCY		FACILITY NUMBER:	013421118
ADMINISTRATOR:	NA, NANCY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 579-6044
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	14	CENSUS: 11	DATE:	06/14/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Nancy Na- Licensee		TIME COMPLETED:	12:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/14/21 at 11:25am, Licensing Program Analysts Briana Plumboy and Sidney Cortez, met with licensee Nancy Na for an UNANNOUNCED ANNUAL INSPECTION. Present for this visit was licensees's fingerprint clear and associated brother/assistant Daniel Na, The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday through Friday from 7:00am until 5:30pm. The home is a two story home. The home appears to be neat and clean with heating and ventilation for safety and comfort during today's inspection. The ON LIMIT AREAS are the living room, kitchen/dining room, hallway bathroom, and the bedroom located on the first level of the home which is located through the first bedroom door on the right. Through the on limit bedroom, there are double doors which lead to a family room which is off limits. The OFF LIMIT AREAS are the family room, garage, and entire second level of the home which will be inaccessible by closed and/or locked doors and visual supervision. There is a child safety gate located at the bottom of the stairs to prevent access to the stairs and second level of the home. The ISOLATION AREA will be the kitchen. The BACKYARD play area is fenced. There are no play structures located in the backyard during today's inspection which are required to be anchored. There are 2 sheds located on the right side of the home which are off limits to children in care and are barricaded to prevent access to children in care. There are toys and learning materials during today's inspection. There are no pools, hot tubs or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that during the inspection there are no toxins or hazardous items accessible to children in care. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, fire alarm, and working telephone. The licensee's CPR and First Aid certificate is current and expires 12/14/21. The licensee and assistant Daniel's mandated reporter training will be emailed to LPA Plumboy. The licensee is in compliance with the immunization law. The fireplace is located in the living room and is screened to prevent access by children. Per 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 5/11/21. (4) Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. See 809-C for continuance

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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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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: NA, NANCY	FACILITY NUMBER: 013421118
	VISIT DATE: 06/14/2021

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

The licensee is aware the safe Sleep Regulations can be found in Title 22, Division 12, Chapter 1, Section 102425.

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 624B). 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

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list

This entire report has been read to the Licensee by LPA Plumboy. The licensee is aware the signature on this report confirm receipt of these documents. LPA asked the licensee if the licensee had any questions pertaining to any aspects including, but not limited to, any part of this report and of the documents given to the licensee, and per licensee, there are no further questions at this time. Licensee is aware at anytime she can reach out to LPA Plumboy or CCLD.

There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC809 (FAS) - (06/04)

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