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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304371193
Report Date: 05/23/2022
Date Signed: 05/24/2022 10:24:49 AM


Document Has Been Signed on 05/24/2022 10:24 AM - 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:NI HAO PRESCHOOL-COSTA MESAFACILITY NUMBER:
304371193
ADMINISTRATOR:BAOQUI XUFACILITY TYPE:
850
ADDRESS:827 W. STEVENS AVETELEPHONE:
(855) 644-2688
CITY:SANTA ANASTATE: CAZIP CODE:
92707
CAPACITY:36CENSUS: 7DATE:
05/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Shah Janki, DirectorTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) P. Rivas conducted an unannounced annual inspection. Director Janki assisted LPA Rivas throughout facility inspection. In order to enter facility, front entrance is located at 1000 Keller Ave. Santa Ana CA 92707.
Ms. Janki reports that a Director's packet was submitted prior to her employment. LPA was provided copy of packet. (today's review of staff record indicated Ms. Janki is qualified as Director)
The floor and yard plan (LIC 999) were verified. The overall census observed was 7 pre-school children and 3 staff(including the director). During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staff to child ratios. Facility hours are 7:30a.m.- 6p.m., Monday through Friday. A review of the Facility Personnel Report Summary on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Facility was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

The items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. Poisons/Hazardous Items are not stored on site and none were observed. Children nap on cots, and bedding is stored separately, and laundered at home on a weekly basis. Food is prepared on site; snacks are provided, and lunches are brought from home. Food prep areas appear clean and sanitary, food is properly stored. The facility has a monthly menu posted and is up to date. There is drinking water available to children both indoors and outdoors via water bottles. The children's bathrooms are clean and sanitary. The last fire drill was conducted on 04/01/22. The facility has a working smoke detector, carbon monoxide detector, and fire extinguisher. The playground is completely fenced and fencing is in good repair.
(continued on LIC809C)
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: NI HAO PRESCHOOL-COSTA MESA
FACILITY NUMBER: 304371193
VISIT DATE: 05/23/2022
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The playground equipment appeared in safe condition, and the play area is free from hazards. There is sufficient cushioning underneath climbing structures and/or play equipment to absorb falls. Sign in/out
procedure was reviewed for compliance. Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department.
Drinking water in the outdoor activity space is provided. The outdoor equipment and toys are in good repair and free of sharp edges. There are no bodies of water present at the facility. The inspected outdoor facility grounds are safe, sanitary and in good repair. Staff files were reviewed for staff present during the facility inspection on this date. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a child care center if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for staff were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all directors and employees to complete mandated reporting training, and to renew the training every two years. At least one staff member present possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires 10/22. Children's records were reviewed, and there was a separate, complete and current record for each child. In the areas reviewed the children’s files were found to be in full compliance. Sign in/out procedure was reviewed for compliance. The person who signs the child in and out uses their full legal signature and records the time of the day. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. The following information regarding ADA 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
The following
The Director was informed that Licensing Quarterly Updates are available at www.ccld.ca.gov Director may request to be added to an email list to receive a Quarterly Update by contacting the Child Care Advocate at childcareadvocatesprogram@dss.ca.gov or at www.ccld.ca.gov
LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian
(continued on LIC809C page 3)
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
Page: 3 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: NI HAO PRESCHOOL-COSTA MESA
FACILITY NUMBER: 304371193
VISIT DATE: 05/23/2022
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Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The facility representative was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the facility representative. Licensee should continue to follow COVID-19 requirements and guidance in all applicable California Department of Social Services (CDSS) Community Care Licensing (CCL) Provider Information Notices (PIN), in addition to guidance or requirements from California Department of Public Health (CDPH), California Department of Industrial Relations Division of Occupational Safety & Health (Cal/OSHA), and local public health departments, as applicable to the facility type. Links to these pages can be found at: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/child-care-licensing/covid-19-child-care-resources

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Appeal Rights and deficiencies were discussed. The Ms. Janki was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee. To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Pat RivasTELEPHONE: 714-703-2800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2022
LIC809 (FAS) - (06/04)
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