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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700241
Report Date: 04/14/2022
Date Signed: 04/14/2022 01:01:35 PM


Document Has Been Signed on 04/14/2022 01:01 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:TSURUTA, YUKIKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 598-7058
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:14CENSUS: 12DATE:
04/14/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Yukiko TsurutaTIME COMPLETED:
01:05 PM
NARRATIVE
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On 04/14/22, Licensing Program Analyst (LPA) Melanie Otsuji met with Licensee Yukiko Tsuruta for an UNANNOUNCED CASE MANAGEMENT INSPECTION. Present for this visit was licensees fingerprint cleared assistant, and 12 children (11 infants and 1 preschooler).

The home was toured for a health and safety inspection. LPA conducted an unannounced inspection to verify the licensee is in ratio. Today, the Licensee has failed to correct the ratio citation. LPA Otsuji took a physical census of the children. Upon arrival at the facility, there were 12 children counted, 11 of which are infants. This is being cited on the 809-D attached. The attached type A violation is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in the child's file to be reviewed by licensing. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and appeal rights provided.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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Document Has Been Signed on 04/14/2022 01:01 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: TSURUTA, YUKIKO
FACILITY NUMBER: 015700241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2022
Section Cited

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102416.5(d)(2)(b) Staffing Ratio and Capacity
For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time... (2) More than twelve... (b) No more than three infants are cared for during any time when more than 12 children are being cared for. This requirement was not met as evidence by:
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Based on inspection and licensee interview, present during today's visit were 11 infant aged children and 1 preschool aged child.
This poses an immediate risk to the health and safety of children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected. A Non-Compliance Conference will be scheduled at a later date.

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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: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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