013422604-2-7-2023-52-CC-AWRT-CNPQVT-20230203113052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013422604
Report Date: 02/03/2023
Date Signed: 02/07/2023 09:46:52 AM

Document Has Been Signed on 02/07/2023 09:46 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	WANG, XIA		FACILITY NUMBER:	013422604
ADMINISTRATOR:	WANG, XIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 303-8225
CITY:	FREMONT	STATE: CA	ZIP CODE:	94555
CAPACITY:	14	CENSUS: 3	DATE:	02/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Xia Wang		TIME COMPLETED:	11:40 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 February 3rd ,2023 at 9:25am, Licensing Program Analyst (LPA) April Wright met with licensee Xia Wang for an Unannounced Required 1 Year Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. There were three (3) children present during today's inspection. Hours of operation are 8am - 6pm Monday through Friday. Due to language barrier, LPA used translation application via mobile phone to communicate during today's inspection. LPA toured the home to conduct a health and safety inspection. The 2 story home was neat and orderly, with heating and ventilation for safety and comfort of children in care. The isolation area is the living room which is a section away from other children in care. The backyard has a play structure and trampoline. Licensee stated that the trampoline is off limits to children in care. On limit areas include: Living / Dining room area (Daycare rooms), bathroom, family room and backyard. Off-limits areas include: Entire second level of home, kitchen, shed and garage. The off limits are and will be made inaccessible by closed and/or locked doors and visual supervision. There is a gate at the bottom of the stairs to prevent access to the upper level of the home. There are no pools hot tubs or any other bodies of water present in the on limit areas during todays inspection. LPA did not observe any hazardous materials or toxins accessible to children during today's inspection. There are ample age appropriate toys that appear to be safe and in good condition. The home has a fully charged 3A40BC fire extinguisher, dual working smoke detector/carbon monoxide and telephone. There is a fire place in the family room that is blocked and inaccessible to children in care. Per licensee there are no firearms in the home. The licensee is in compliance with the immunization laws which pertains to all childcare providers. See LIC 809C for continuance.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: April Wright	TELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: WANG, XIA	FACILITY NUMBER: 013422604
	VISIT DATE: 02/03/2023

NARRATIVE

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LPA requested and reviewed the files of three (3) children in care. The children's files contained, Parents rights, medical consent forms and identification and emergency contacts. The facility roster was reviewed and copies were obtained. The licensee conducts fire and disaster drills twice a year and the last was conducted on 8/18/2022. The licensee has a current CPR/First aid certificate which expires in January 2024. The licensee had previous a waiver for the Mandated reporter training. LPA advised licensee that mandated reporter training is now available in her native language. Licensee will complete training and forward certificate of completion to LPA when completed. The training can be found at mandatedreporterca.com. The licensee is in ratio today. All required forms are posted and visible for public review.

Incidental Medical Services (IMS) policy was discussed. No IMS provided at this facility. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

California Law requires Child Care Centers 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 624). 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 is reminded any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. LPA discussed the Safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep webpage https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource.

See LIC 809c for continuance..

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: April Wright	TELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: WANG, XIA	FACILITY NUMBER: 013422604
	VISIT DATE: 02/03/2023

NARRATIVE

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Licensee 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.

There are no deficiencies cited. A Technical Advisory was given to Licensee to remind that Mandated Reporter training in available and can be completed in their native language.

A notice of site visit was given and must remain posted 30 days. Exit interview conducted and report was review with licensee Xia Wang.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: April Wright	TELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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