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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422785
Report Date: 08/09/2019
Date Signed: 08/09/2019 01:46:45 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:SHA SONGFACILITY NUMBER:
013422785
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
08/09/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Sha SongTIME COMPLETED:
02:00 PM
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On 08/09/19, Licensing Program Analysts M. Guirit and D. Campos, met with licensee Sha Song for an UNANNOUNCED RANDOM INSPECTION FOR CHANGE OF CAPACITY. Present for this inspection was applicant, fingerprint cleared mother, Qinqin Zhao, Aunt who is only visiting for today, 13 year old daughter, 18 month old son, 2 infants,and 2 preschoolers. Fingerprint cleared husband, Ba Ngo, also resides in the home but was not present for today's inspection. The fire clearance was reviewed and was granted on 07/03/2019. The home was toured to conduct a Health and Safety Inspection. The facility hours of operation are from 7:30 AM to 6:00 PM.

The home is one story. The home consists of living room, kitchen area, 3 bedrooms, 2 bathrooms, attached garage, and backyard. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the living room, first bedroom to the left, last bedroom to the left, hallway bathroom, and backyard. The OFF LIMIT AREAS are the kitchen, master bedroom/bathroom, and garage which will be inaccessible by closed and/or locked doors, child locks, and visual supervision. The ISOLATION AREA will be the last bedroom to the left. The outdoor play area is free from defects or dangerous conditions and is completely fenced. 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. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.

The home has a fully charged 2A10BC fire extinguisher, approved fire alarm by the Fire Dept., working smoke detector, working carbon monoxide detector, working telephone, and fully stock First Aid Kit. The licensee CPR and First Aid certificate is current and expires 04/06/2021. Licensee's mother assists with the child care and has all the appropriate forms and immunizations. Licensee's mother has CPR/First Aid which expires 07/13/2021. Licensee is in compliance with the new immunization law. The heater is mounted on the wall high enough where children cannot reach. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last drill taking place on 02/2019. See 809-C for continuance.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa GuiritTELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
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 2
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: SHA SONG
FACILITY NUMBER: 013422785
VISIT DATE: 08/09/2019
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(4) Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov .http://www.myccl.gov/

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

There are no deficiencies cited. Capacity change will remain pending per manager approval. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and appeal rights provided.

SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa GuiritTELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2019
LIC809 (FAS) - (06/04)
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