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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422682
Report Date: 01/31/2020
Date Signed: 01/31/2020 04:38:39 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SHI, WENYINGFACILITY NUMBER:
013422682
ADMINISTRATOR:SHI, WENYINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 860-8556
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:14CENSUS: DATE:
01/31/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Wenying ShiTIME COMPLETED:
04:50 PM
NARRATIVE
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On 01/31/2020 at 02:50 PM Licensing Program Analysts (LPAs) Arminder Singh and Monica Mathur met with Licensee, Wenying Shi for an unannounced random annual inspection and explained the purpose of today's inspection. During the inspection her Assistant, who is fingerprint cleared was present. In today's inspection there are 11 preschoolers present. Days and hours of operation are Mon - Fri, 7 AM to 5:30 PM.

At 03:05 PM the home was toured to conduct a health and safety inspection. The home is a one story home, consists of a kitchen, living room, one bedroom, one bathroom, and a backyard that has a laundry room (locked). The ON LIMIT AREAS are the living room, kitchen, bedroom, bathroom, and the outside yard which is located on rear of the home. The entrance to the yard is through the side gate. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs, or any other bodies of water.

The home has a fully charged 3A40BC fire extinguisher, working smoke detector, and carbon monoxide detector. There is centralized heating that is working and in good repair. Licensee states there are no firearms in the home. Licensee does have a pet dog. The bedroom is the isolation room. She has a first aid kit.

At 03:40 PM eleven (11) child's records (C1-C11) were reviewed by the LPAs and the licensee. Files are complete. Licensee and assistant have current Pediatric CPR and First Aid certificates are current and expire on 05/2021(licensee) and 06/2021 (assistant). Mandated reporter training is current.

Please see LIC 809 C for additional information
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Arminder SinghTELEPHONE: (510) 622-2634
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
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 3
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SHI, WENYING
FACILITY NUMBER: 013422682
VISIT DATE: 01/31/2020
NARRATIVE
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This facility is not providing Incidental Medical Services - IMS at this time. LPA discussed IMS services and the requirement to create a plan of operation.
REMINDERS/RESOURCES
Criminal Background Clearance: All assistants, volunteers, frequent adult visitors (adults are individuals 18 years of age or older) must be fingerprint cleared and associated to the facility prior to be in the presence of children in care. Failure to comply, requires an immediate civil penalty of $100 to $3000 per person, per incident.

· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

· NEW LAW: Safe Sleep Regulations: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep

- LPAs provided Lead Poisoning Information Flyer.

Licensee is reminded that while children are playing in side yard or going on trips to the park that there should be 100% supervision.

-LPA's discussed that any food brought from the child's home should be properly labeled

LPA's reminded licensee to submit an updated sketch for the facility.

· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse. Mandated reporters are valid for two years after completion.

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov or send email Child Care Advocate Program.

Deficiency was cited during today's inspection. Please see 809-D page.

At 04:30 PM exit interview was conducted where this report, citations, plan of corrections, and appeal rights were discussed. A NOTICE OF SITE VISIT was issued and must remain posted for 30 days.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Arminder SinghTELEPHONE: (510) 622-2634
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SHI, WENYING
FACILITY NUMBER: 013422682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2020
Section Cited

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102417(g)(9) Operation of a Family Child Care Home. Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. [...] This requirement was not met as evidenced by:
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Per LPA's observation licensee did not have posting of Emergency Disaster Plan for Family Child Care Homes (LIC 610a). This poses a potential risk to the health and safety of children in care.
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Type B
02/07/2020
Section Cited

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102417(b) Admission Procedures and Parental and Authorized Reprenative's Rights. The licensee shall post the PUB 394 (8/02). [...] This requirement was not met as evidenced by:
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LPA's observation licensee did not have posting of the PUB 394 (8/02). This poses a potential risk to the health and safety of children in care.
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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: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Arminder SinghTELEPHONE: (510) 622-2634
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3