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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700241
Report Date: 03/04/2022
Date Signed: 03/04/2022 01:08:00 PM


Document Has Been Signed on 03/04/2022 01:08 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:TSURUTA, YUKIKOFACILITY NUMBER:
015700241
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
03/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Yukiko TsurutaTIME COMPLETED:
01:27 PM
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At 11:50AM Licensing Program Analysts (LPAs) Melanie Otsuji and Julia Placencia arrived to the facility unannounced to conduct a Case Management visit for an INCREASE IN CAPACITY. LPA was met by Licensee Yukiko Tsuruta. Present during today's visit was the a fingerprint cleared assistant and 6 children (3 infants and 3 preschoolers).

LPAs conducted a health and safety inspection of the facility.
ON LIMIT AREAS: play room, living room, downstairs bedroom, downstairs bathroom, and playground.
OFF LIMIT AREAS:: entire second floor, kitchen, garage, backyard area fenced off from the playground.
ISOLATION AREA: living room.

On this date, the facility is within the capacity specified on the license. The home is kept clean, safe, sanitary and in good repair. The home has a 3A40BC fire extinguisher, working smoke and carbon monoxide detectors. LPA conducted a file review and all children's files contain the necessary documents. Outdoor play area is fenced and supervised by the Licensee.

The fire clearance for the increase in capacity was received and approved on 1/19/2022.

No deficiencies are being cited. This home is recommended for the capacity increase as of today's date. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. This report shall remain on file for 3 years. Exit interview conducted with licensee. Notice of Site Visit provided and must be posted for 30 days.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022
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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