198003578-10-9-2019-33-CC-JHUA-BGSLNV-20191009085458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198003578
Report Date: 10/09/2019
Date Signed: 10/09/2019 08:55:03 AM

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:	GU FAMILY CHILD CARE		FACILITY NUMBER:	198003578
ADMINISTRATOR:	GU, XIAOLING		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 855-0598
CITY:	HACIENDA HEIGHTS	STATE: CA	ZIP CODE:	91745
CAPACITY:	14	CENSUS: 0	DATE:	10/09/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	07:59 AM
MET WITH:	Xiaoling Gu		TIME COMPLETED:	09:05 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Annual random inspection conducted by LPA Jennifer Hua. LPA Met with licensee, who guided the analyst on a tour of the facility. The facility is a two-story home, Licensee speak primarily Mandarin and some English. Per licensee, people live in the home are 2 adults and 0 minor. Per licensee, only caring for 3 school-age children. Licensee's spouse was also present during this visit. Areas used by children were inspected as follows: Bedroom next to enclosed patio and hall bathroom. 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 and is fully charged and was purchased on 9/17/19. Areas off limits include: bedroom downstairs, enclosed patio, second level, kitchen, living room and front and backyard. Per licensee, children do not play outside as they are here only for a couple of hours. -Licensee and spouse are current in Pediatric CPR/First Aid expires 9/15/2021 -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/working in the home must be finger print cleared prior to being on the premise. Individuals within one month of their 18th birthday must be fingerprinted immediately. 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 Chico	TELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer Hua	TELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2019

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: GU FAMILY CHILD CARE	FACILITY NUMBER: 198003578
	VISIT DATE: 10/09/2019

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Rooms that are off-limits need to be made inaccessible during operating hours. 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 conducted on 9/7/19. Affidavit Regarding Liability Insurance form in files. Licensee was informed to complete the Mandated Reporter Training on department website at http://www.mandatedreporterca.com/ if training is available in her language. .

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

· Dog(s) and or pets should be isolated from children in care. No pets
· It is recommended that a First Aid kit be available on premises.
Outdoor supervision required at all times. If outdoor area not adequately fenced provider must be with children at all times when outdoors.

No deficiencies cited.

Exit interview was conducted with licensee.
Site visit notice posted. And Licensee advised to keep notice posted for 30 days.
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 Chico	TELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer Hua	TELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2019

LIC809 (FAS) - (06/04)

Page: 2 of 2