013421118-5-25-2022-52-CC-KPHN-CERP6W-20220525110302

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013421118
Report Date: 05/25/2022
Date Signed: 05/25/2022 11:03:14 AM

Document Has Been Signed on 05/25/2022 11:03 AM - 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:	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: 8	DATE:	05/25/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Nancy Na		TIME COMPLETED:	11:20 AM

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 05/25/2022 approximately at 9:05AM, Licensing Program Analyst (LPA) Kelly Phan arrived at for an unannounced required inspection, and met with Licensee Nancy Na. Present for this inspection was the licensee, fingerprinted and associated helper, along with 2 infants and 6 preschool aged children. Also residing in the home is the licensee's fingerprinted husband, their fingerprinted adult daughter, and their two other children (13 and 6). The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 7:00am to 5:30pm. ON LIMITS: living room (main day care area), kitchen.dining room, hallway bathroom, bedroom closest to the kitchen/dining room, backyard; isolation would be the kitchen OFF LIMITS: Entire second floor, garage, family room, and side yards. Off limit areas are inaccessible by closed and/or locked doors, gate for the staircase, and visual supervision. The home is single story, which is neat and clean, with heating and ventilation for safety and comfort. A child safety gate is required at the stairway as the Licensee is using a gate to keep children in the living room area. There were ample age appropriate toys that were observed to be safe and in good condition. There were no toxins, medicines, and hazardous items were inaccessible during today's inspection. There were a 2A10BC fire extinguisher. However at 9:25AM, LPA observed that the fire extinguisher was not fully charged; Licensee states that she had a fire inspection last month. LPA suggests to licensee that she could get it recharged by the Fire department or purchase a new one; a Technical violation was issued. The facility has a dual carbon monoxide and smoke detector and a working telephone. The home has a fireplace but is blocked off by a glass mirror. Per licensee, there are no firearms or any bodies of water in the home. The facility does have a dog but per licensee, it is always on the second level of the home. The licensee conducts and documents fire drill log indicates a drill was conducted 05/02/22. All required licensing documents are posted and visible for public review. SEE LIC 809 C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

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: NA, NANCY	FACILITY NUMBER: 013421118
	VISIT DATE: 05/25/2022

NARRATIVE

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At 10:00am, 6 children's files were reviewed and there was 1 child's file that was missing the LIC 995A (Notification of Parent Rights). LPA informs licensee to have the child's parent sign the form and send proof to LPA by 05/27/2022. The facility roster was reviewed, and a copy obtained. The licensee is in ratio today. Licensee and helper has proof of the required immunization. The licensee and helper have required mandated reporter training that is completed as of 05/16/2018.. Both licensee and her helper has current CPR and First Aid training that is valid until 02/19/2024

There were no deficiencies were cited for today's inspection

Appeal rights and a notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00. Exit interview conducted and report was reviewed with licensee Nancy Na

LPA discussed the safe sleep regulations with licensee 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 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.

SEE LIC 809 C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

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: 05/25/2022

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Incidental Medical Services (IMS) policy was discussed. This facility does not provides IMS to children in care.. 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.”

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.

Licensee was reminded that California Law requires licensed Child Care Centers 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. LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

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.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2022

LIC809 (FAS) - (06/04)

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