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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700241
Report Date: 04/22/2022
Date Signed: 04/22/2022 01:46:15 PM


Document Has Been Signed on 04/22/2022 01:46 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: 6DATE:
04/22/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Yukiko TsurutaTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Melanie Otsuji arrived to the facility unannounced to conduct a Plan of Correction (POC) visit. Present during today's visit was the Licensee, Yukiko Tsuruta, a fingerprint cleared assistant and 6 children (3 preschoolers, 3 infants).

The following corrections have been made:

1) 102416.5(d)(2)(b) Licensee is now within the appropriate ratio.

LPA notes that all children present had the proper signed LIC 9224 in their file. There are no deficiencies cited today. Copy of Cleared POC's letter provided.

An exit interview was conducted. This report must be available for review for 3 years. A notice of site visit was posted. Notice of site visit must remain posted for 30 days.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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