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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422775
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:44:43 PM


Document Has Been Signed on 02/17/2022 03:44 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:WANG, LIQINGFACILITY NUMBER:
013422775
ADMINISTRATOR:WANG, LIQINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 709-1181
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:14CENSUS: 10DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Liqing WangTIME COMPLETED:
03:50 PM
NARRATIVE
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On February 17, 2022 at approximately 11:30am Licensing Program Analyst (LPA) Haderer met with the licensee Liqing Wang for the purpose of conducting an unannounced 1-year annual inspection for Health and Safety compliance. Present for today’s inspection was the licensee, her TB and fingerprint cleared assistant and 10 children in care (10 toddlers). Hours of operation remain the same at 9:00am to 6:30pm.

The facility is a two-story home with 4 bedrooms, 2 ½ bathrooms, a kitchen, dining room, living room, family room and an attached 2-car garage, front, back and side yards. There is a disused fireplace in the living room completed covered and sealed off, there is an additional screened fireplace in the family room. The home also has an attached one bedroom mother-in-law apartment, tenants are not present during day care activities. The home on and off limits will remain as originally licensed.



ON LIMIT AREAS: Living room, dining room, family room , downstairs ½ bathroom near the small garage door, the front, southside and back yards. Licensee was reminded that other than wipes or things used for the children in the on limits children’s bathroom, they need to be empty of most all items (or locked up) such as cleaning products.
OFF LIMIT AREAS: The entire upstairs and bedrooms, the one room mother-in-law apartment and attached 2-car garage, north side yard. The off-limit areas will be inaccessible by child gates, closed and/or locked doors and adult supervision.

There is a large play structure in the front yard that is free from hazards and has soft materials underneath. The front yard has a fence surrounding the area, children are supervised at all times while playing. Licensee has ample age-appropriate toys and learning materials (Montessori style) inside the home. There is a large fish tank in the living room with goldfish and only filled halfway. The children can look at the fish but is it out of reach to them. The home has a fully charged 2A10BC fire extinguisher in the entryway, smoke detectors and carbon monoxide detector (all tested and working) and a working telephone.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
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: WANG, LIQING
FACILITY NUMBER: 013422775
VISIT DATE: 02/17/2022
NARRATIVE
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At 1:30pm, LPA reviewed facility files including records for licensee and assistants and the Children’s files. The licensee’s Health and Safety training is completed. Both the licensee and helper have current CPR and First Aid certificates, both expire 8/14/2023. Mandated Reporter training was completed 3/18/2020 (licensee), helper was completed 9-19-2021. Licensee was reminded that CPR/1st Aide and Mandated Reporter is to be renewed every two years. The licensee is in compliance with the immunization laws which pertains to day care providers.

Children’s files were complete and well organized, however, two children’s files with the LIC627 Consent for Medical Services form did not have the parent’s signatures. In addition, a child’s file did not contain the signed LIC995A Parent’s Rights form. See LIC809D for deficiencies.

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

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.



LPA discussed the safe sleep regulations with licensee [or facility representative] 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 [facility representative] 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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: WANG, LIQING
FACILITY NUMBER: 013422775
VISIT DATE: 02/17/2022
NARRATIVE
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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/inspection-process.

LPA reviewed guidance on operating safely during the Covid pandemic. Posters were present and the checking in process of children was reviewed.



There were two deficiencies issued today, see LIC809D for details. The report will remain on file for three years.

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



Exit interview conducted and report was reviewed with the licensee LiQing Wang.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/17/2022 03:44 PM - It Cannot Be Edited

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: WANG, LIQING
FACILITY NUMBER: 013422775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 2 out of 10 children's files had the LIC627 Consent for Medical Treatment form, however, they were not signed by the parents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee will have the parent's sign the consent form at the time of pick up.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 02/17/2022 03:44 PM - It Cannot Be Edited

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: WANG, LIQING
FACILITY NUMBER: 013422775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 10 of the children's files reviewed did not contain the required LIC995A signed Notice of Parent's Rights form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/18/2022
Plan of Correction
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Licensee will have the parent's fill out and sign the Notice of Parent's Rights form.

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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6