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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700241
Report Date: 06/07/2021
Date Signed: 06/07/2021 11:47:40 AM

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:TSURUTA, YUKIKOFACILITY NUMBER:
015700241
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
06/07/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Yukiko TsurutaTIME COMPLETED:
12:08 PM
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On 06/07/2021 at 9:00am Licensing Program Analyst (LPA) Jonathan Williams met with Applicant, Yukiko Tsuruta, for the purposes of conducting an announced prelicensing inspection for a change of location. Present during today's inspection was the Applicant and the Applicant's fingerprint cleared and associated spouse. All adults in the home are fingerprint cleared and associated. The home was toured to conduct a health and safety inspection.

On-limit-areas: play room, living room, downstairs bedroom, downstairs bathroom, playground.
Off-limit-areas: entire second floor, kitchen, garage, backyard area fenced off from the playground.
Isolation area: downstairs bedroom.

The facility is a two-story home rented by the Applicant. The home is neat and clean. All toxins, medications, hazardous materials, and cleaning compounds were observed throughout the inspection to be made inaccessible to children. Per Applicant statement at 9:30am, there are no firearms in the facility. Per Applicant statement at 9:35am, there are no pets kept in the home. A 3A40BC fire extinguisher was observed at 9:40am to be located in the kitchen. Applicant tested carbon monoxide and smoke detectors and LPA observed them to be functional at 9:43am.

The backyard was toured at 10:00am. The backyard is fenced. The on-limits playground area was observed to be undergoing construction at the time of this inspection. LPA did not observe any bodies of water on the facility premises at this time and per Applicant statement at 10:18am, no bodies of water are located on the facility premises.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: TSURUTA, YUKIKO
FACILITY NUMBER: 015700241
VISIT DATE: 06/07/2021
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Applicant has required Preventive Health and Safety Training certificate. Applicant has current CPR/1st Aid certificate which expires on 10/17/2022. Mandated Reporter training certificates for "Child Care Providers" and "General" for Applicant are current, and expire on 04/17/2023.

LPA discussed all records to be maintained, including children's files and required COVID-19 postings, with Applicant at 10:25am. Applicant provided COVID-19 Self-Assessment Guide and all answers were discussed. COVID-19 postings were provided to Applicant. LPA provided technical assistance regarding all COVID-19 policies and procedures.

Applicant 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. Applicant was reminded of the responsibility of a mandated reporter.



Applicant was reminded that California Law requires licensed Family Child Care Home 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. LPA informed the Applicant that all forms can be downloaded at www.ccld.ca.gov and encouraged the Licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Applicant was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed at 11:31am. Applicant was reminded that when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: TSURUTA, YUKIKO
FACILITY NUMBER: 015700241
VISIT DATE: 06/07/2021
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The Applicant is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing.

Due to the following deficient conditions, a license cannot be issued at this time. Applicant shall complete the following before licensure can be recommended:

1. A fully stocked first aid kit must be present in the facility.
2. The staircase leading to the second floor (off-limits) must be barricaded to prevent access by children.
3. Ample toys and learning materials must be present in the facility.
4. Napping and sleeping equipment must be present in the facility.
5. Facility sketch must match the facility itself, including all off-limits areas marked.
6. Renovations to outside play area must be complete.

If the above corrections are not made by the due date of 7/7/2021, a license cannot be issued.

Appeal Rights provided and exit interview conducted at 11:34am.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR NAME: Jonathan WilliamsTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
LIC809 (FAS) - (06/04)
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