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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421118
Report Date: 07/26/2023
Date Signed: 07/26/2023 12:17:22 PM


Document Has Been Signed on 07/26/2023 12:17 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:NA, NANCYFACILITY NUMBER:
013421118
ADMINISTRATOR:NA, NANCYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 579-6044
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:14CENSUS: 11DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Nancy NaTIME COMPLETED:
12:15 PM
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On 7/26/2023 at 9:36am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Nancy Na for a Required – 1 Year Inspection. Present during the inspection was the Licensee, her helper D. Na, her seven (7) year old son, four (4) infants and six (6) preschool age children. Licensee’s adult daughter, J. Na Standfield, and fifteen (15) year old son were present in the home but remained in off-limit areas. Licensee lives in the home with her husband, J. Standfield, her adult daughter and their two (2) minor children. The facility operates 7:30am – 5:30pm, Monday - Friday.

ON LIMITS AREA: Living Room, Kitchen, Dining Area, Downstairs Bathroom, Downstairs Bedroom (used mainly for infant sleeping) and Backyard
OFF LIMITS AREA: Entire 2nd floor, Media Room/Family Room (behind on-limits bedroom), Garage, and both sides of the backyard
ISOLATION AREA: Kitchen

The facility is a two-story home owned by the Licensee. The inside of the home is observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, personal medications, and hazardous materials were observed to be in inaccessible areas. All off-limit areas were made inaccessible with locks, gates, and closed doors. Licensee has stated that there are no firearms and one (1) dog in the home.

The home has one (1) fully charged 2A10BC fire extinguisher in the pantry. There is a combination smoke/carbon monoxide detector in the downstairs hallway, and one (1) smoke detector in the bedroom. The home is equipped with central heat and air for proper ventilation.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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: 07/26/2023
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 Licensee provides all food for the children. All food that is brought from the children’s home will be properly labeled and stored. There are three (3) cribs used for infant sleeping. All cribs are clean and in good condition. All other napping equipment is properly stored, and well maintained. The staircase is gated making it and the second floor inaccessible to the children in care. The fireplace in the living room is blocked by furniture making it inaccessible as well. Licensee stated she does not transport children.

The backyard is fully fenced with ample age-appropriate materials for the children in care. There are two (2) storage sheds on the sides of the home that are gated making them inaccessible to the children in care. The off-limit sides of the home are gated as well. LPA did not observe any harmful bodies of water in or around the home.

Licensee is operating within their licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed and Pediatric CPR and First Aid training is complete and expires 2/19/2024. Licensee’s Mandated Reporter training is complete and expires 6/22/2025. All required forms are posted and visible for public view in the living room. Licensee’s fire drill log is complete with the last drill logged 5/2/2023. All adults living, working and/or volunteering in the home have obtained a criminal record clearance. LPA obtained the children’s files, helpers file, and facility roster. All files were complete.

No deficiencies were cited during the inspection.

Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or email. Licensee was reminded that any structural changes or additions to the home must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting https://mandatedreporterca.com/. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
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: 07/26/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Nancy Na, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 07/26/2023
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

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

Exit interview conducted and report was reviewed with the Licensee Nancy Na.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5