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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406289
Report Date: 06/04/2019
Date Signed: 06/04/2019 11:58:11 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:PETERSON, WEN-HSIANG & MARKFACILITY NUMBER:
073406289
ADMINISTRATOR:PETERSON, WEN-HSIANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 965-9461
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:14CENSUS: 7DATE:
06/04/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Hsiang Wen-PetersonTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Paul Petersen conducted an unannounced random annual site inspection for this facility on 06/04/19 at 0945. LPA met with licensee, Hsiang Wen-Peterson, and toured all areas on limits to children in care for a health and safety inspection. Also present at the time of this inspection were assistant, Huang Ho, and six preschool age children in care. One additional preschool age child arrived while LPA was present making a total of 7 preschool age children in care. The facility is within ratio and capacity. The on limits areas for children in care are the living room, the back to childcare/play rooms, and the hallway bathroom. The remainder of the home including the entire upstairs is off limits to children in care and made inaccessible by closed doors, child safety door handles and visual supervision at all times. There is child safety gating at the base of the stairs. Hazardous items are stored inaccessible to children and no hazardous items/toxins were observed to be accessible to children in care. Per licensee, there are no firearms stored or present on the premises. There are ample age appropriate toys, equipment and furnishings, which appear to be free of broken/sharp pieces. The fireplace is screened to make inaccessible to children in care.. The home has heating and ventilation for temperature management. There is a fully fenced outdoor patio/play area which is available to children in care. The gated off sections/storage areas of the outside area is off limits to children in care and gates to the area is to be kept closed at all times children are outside. The out door play equipment is age appropriate and free of broken pieces. There are no pools, hot tubs or other accessible bodies of water. There is a fully charged fire extinguisher, a working carbon monoxide detector and multiple working smoke detectors. Assistant's CPR/First Aid is current and expires 04/2021. LPA reviewed the Facility Personnel Report Summary with licensee and verified that all adults requiring background clearances are cleared and associated to this facility. A review of the facility, staff and children's records was conducted including children's emergency ID forms, parent's rights forms and children's immunization records. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. 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 Contact childcareadvocatesprogram@dss.ca.gov to sign up for quarterly updates. For licensing forms and updates visit www.ccld.ca.gov
There were no deficiencies cited during this inspection. A copy of the Safe Sleep for Child Care Providers was issued and discussed. LPA printed and provided a copy of the appeal rights. The notice of site visit was provided and is to remain posted at this facility for 30 days from today's date. A copy of this report is to be available in the facility records for a period of three years.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Paul PetersonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2019
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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