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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198003142
Report Date: 06/15/2021
Date Signed: 06/15/2021 04:53:04 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:SHI AND LIU FAMILY CHILD CAREFACILITY NUMBER:
198003142
ADMINISTRATOR:SHI, YIN JIAO; LIU, JIAN FFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 288-6972
CITY:ROSEMEADSTATE: CAZIP CODE:
91770
CAPACITY:14CENSUS: DATE:
06/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Yin Jiao Shi & Jian Feng LiuTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Bardo Baluyot conducted an unannounced required annual inspection of the above facility on 06/15/2021. LPA arrived at the facility at 3:15 PM and met with licensees, who guided the analyst on a tour of the facility on this date. Licensees speak Cantonese & Mandarin and some English. This visit was conducted in English. Per licensee, total 2 adults reside in the home full time and adult children only visit occasionally. Areas accessible to children were inspected as follows: Entire middle portion of the home, hall bathroom, 2 bedrooms, kitchen area, fenced patio, fenced driveway/yard use for outdoor play. Per licensee, there are no weapons, firearms, swimming pool or spa on the premises. The backyard is adequately fenced. There are age appropriate toys and equipment on the premises. The smoke/carbon monoxide detectors and fire extinguisher (2A 10BC) are in operable condition. Fire extinguisher was serviced on 2/19/21.
Areas off limits include: Entire front portion of the home with separate entrance (2 bedrooms, 1 bathroom) 1 bathroom in middle portion of the home. Entire back portion of the house which is newly added with separate entrance. It's second story consists of 5 rooms and 4 bathrooms. Door leading to the addition has safety knob.
-Licensees are current in Pediatric CPR/First Aid which will expires 9/12/22.
-Child Care Roster, Disaster Plan, and Children's Records were reviewed.
-Children records and required licensing forms were discussed as well as mandated child abuse reporting and criminal records clearance (finger prints and child abuse clearance) requirement.
The following was discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to be on premise. Individuals within one month of their 18th birthday must be fingerprinted immediately. The existing, immediate $100 per individual Civil Penalty has been increased to an immediate $100 per day Civil Penalty, for a maximum of five days for the first violation and a maximum of 30 days for subsequent violations. If an individual has a clearance with the Department a criminal record clearance may be transferred. LIC 9182 Criminal Background Clearance Transfer Request may be used.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: SHI AND LIU FAMILY CHILD CARE
FACILITY NUMBER: 198003142
VISIT DATE: 06/15/2021
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Rooms that are off-limits need are made inaccessible by child safety gates at all points of entry. (Photos taken) No smoking, No infant walkers, Johnny jumpers, exersaucers, bouncers and any other item that falls into that category, earthquake – fire, disaster drills and safety, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal records, child abuse clearance and criminal records transfer requirements, SIDS, Never Shake A Baby, Drills last conducted was on 6/04/2021. A Child Care Provider's Guide to Safe Sleep was provided to licensee. LPA observed child care policy in place, will expire on 7/26/22. Licensees have completed the Mandated Reporter Training on department website at http://www.mandatedreporterca.com/ on 10/08/2022.
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0388 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
· LPA verified that a First Aid kit is available on premises. LPA reminded licensee that outdoor supervision required at all times.

At this time, licensees are in compliance with California Title 22 Regulations. No deficiencies cited.

- Exit interview was conducted with licensees. Notice of Site Visit form was provided and explained. The notice shall be posted for 30 days or a civil penalty of $100 will be assessed.

Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l
INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 981-3351
LICENSING EVALUATOR NAME: Bardo BaluyotTELEPHONE: (323) 981-3350
LICENSING EVALUATOR SIGNATURE:

DATE: 06/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021
LIC809 (FAS) - (06/04)
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