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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423145
Report Date: 08/03/2021
Date Signed: 08/03/2021 05:33:07 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:SU, HANGFACILITY NUMBER:
013423145
ADMINISTRATOR:SU, HANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 474-8147
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:14CENSUS: DATE:
08/03/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
04:55 PM
MET WITH:Hang SuTIME COMPLETED:
05:35 PM
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On August 3, 2021 at approximately 4:59pm Licensing Program Analyst (LPA) Russ Haderer met with licensee Hang (Hailey) Su for the purpose of conducting an announced inspection to view new on-limits and off-limits areas of the home. Present for today’s inspection was licensee’s fingerprint and TB cleared mother in-law, father in-law and husband, and 7 children in care today: one infant, five 2-year olds and one 3-year old.

The licensee recently requested to add a children’s day care area and switch an on-limits and off-limits bathroom.

New On-limit-areas include: Living room (activity classroom), dining room (new – kid’s area), main house bathroom, back patio, back left bedroom (for napping). Licensee 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. There are no accessible hazardous cleaning chemicals or other liquids in the on-limits area.

New Off-limit-areas include: Reminder of the home’s bedrooms 1, 2 and 3 (including the master bedroom w/bathroom), bathroom in napping room (bedroom 4), kitchen, eat-in dining room, attached 2-car garage. Off limit areas are inaccessible by closed and/or locked doors and visual supervision. Licensee is aware she must contact licensing so that an inspection can be completed prior to changing an off limits area to on limits.


The new on-limits and off-limits as described above are approved as of this day, August 3, 2021.

LPA left facility at 5:35pm.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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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