<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016331
Report Date: 02/18/2020
Date Signed: 02/18/2020 11:11:00 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:CAI FAMILY CHILD CAREFACILITY NUMBER:
198016331
ADMINISTRATOR:CAI, FENG SIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 587-2315
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY:14CENSUS: 3DATE:
02/18/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Feng Si CaiTIME COMPLETED:
11:20 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 inspection conducted by Licensing Program Analyst (LPA) Jennifer Hua. LPA met with licensee who guided LPA on a tour of facility. Licensee's father Lizhan Cai and sister in law Jinrong Li were also present. All adults present have fingerprint clearances. The facility is a single story dwelling, with 3 bedrooms and 2 bathrooms. Licensees speak primarily Cantonese and Mandarin and some English. This visit was conducted in Cantonese. Per licensee, people live in the home are 6 adults and 1 minor. During visit, a parent was also present since it's her child's first day.
Areas used by children were inspected as follows: Kitchen area(eating only), living room, bathroom and 1 bedroom use for napping and fenced backyard.
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 12/30/19.
Areas off limits include: 2 bedrooms and one bathroom, kitchen and back room behind kitchen and front yard.
-Licensee and her spouse are current in Pediatric CPR/First Aid. Certificates will expires 2/1/2022.
-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. 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) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020
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 3
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: CAI FAMILY CHILD CARE
FACILITY NUMBER: 198016331
VISIT DATE: 02/18/2020
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, A Child Care Provider's Guide to Safe Sleep and Lead Poisoning Facts handout was provided to licensee. Drills were conducted on 1/27/20. Affidavit for Liability insurance form in children's files. Licensee was informed to complete the Mandated Reporter Training on department website at http://www.mandatedreporterca.com/, if the 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.

NOTE: Per licensee, will submit copy of LIC 508, current T.B. test for her brother and sister in law who recently moved in, an updated LIC 279 to include all adults in the home. Submit all documents by 2/28/20.

Deficiency cited on attached 809D.. 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 ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: CAI FAMILY CHILD CARE
FACILITY NUMBER: 198016331
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/19/2020
Section Cited

1
2
3
4
5
6
7
Personal Rights
Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: To receive safe, healthful and comfortable
8
9
10
11
12
13
14
accommodations, furnishings, and equipment. This requirement is not met by evidenced by: A crib that do not meet Federal Standards observed in napping room. This equipment is prohibited in the day-care. This poses a potential risk to the health and safety of the children in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Ana ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3