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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
343621189
Report Date:
05/24/2023
Date Signed:
05/24/2023 07:14:46 PM
Document Has Been Signed on
05/24/2023 07:14 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
ADMINISTRATOR:
FU, YALI
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(916) 893-3063
CITY:
ELK GROVE
STATE:
CA
ZIP CODE:
95757
CAPACITY:
14
CENSUS:
18
DATE:
05/24/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:30 AM
MET WITH:
Yali Fu
TIME COMPLETED:
06:30 PM
NARRATIVE
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On 05/24/2023 Licensing Program Analyst (LPA) Corina Beckby, conducted an unannounced annual inspection and met with Licensee, Yali Fu. Form (LIC 126), Entrance Checklist for Family Child Care Homes, was provided to Licensee. Present in the facility was Licensee and adult (uncleared through Guardian) caring for 18 children, all under the age of 5 including one infant. Facility hours of operation are Monday-Friday 8:00 am to 6:00 pm. LPA verified the annual fees are current. Licensee and LPA communicated via google translate on many occasions.
Licensee stated no new residents have moved into the home; however, adult son lives at home and is not fingerprinted. Licensee was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care Home.
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.
A health and safety inspection was conducted in all areas accessible to children.
LPA did not observe the posting of the facility license, Emergency Disaster Plan, Earthquake Preparedness Checklist and Notification of Parent Rights.
Off-limit rooms are: laundry room, upstairs, garage and shed.
Off-limits areas will remain inaccessible to children by closed doors and/or supervision. The licensee acknowledges that she must contact LPA prior to making an off-limits area on-limits and vice versa.
Continued on LIC809C...
SUPERVISOR'S NAME:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
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of
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Document Has Been Signed on
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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
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in which a carbon monoxide detector was not plugged in nor working, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/25/2023
Plan of Correction
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2
3
4
Licensee will purchase a carbon monoxide detector and leave it plugged in at all times. LPA will return to verify compliance.
Type A
Section Cited
CCR
102417(g)(4)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in which cleaning detergents were accecible to children, insect killer was accesible to children, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/25/2023
Plan of Correction
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2
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Cleaning agents were moved and placed out of reach of children during inpsection. CItation was corrected at time of visit.
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:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
2
of
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Document Has Been Signed on
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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
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in which assistant is not fingerprinted and adult son who lives in the home is not fingerprinted, either, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
05/25/2023
Plan of Correction
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Son will get fingerprinted and assistant is not allowed back until fingerprints have cleared.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
3
of
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Document Has Been Signed on
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- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 count of the gate leading to the upstairs was not closed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/25/2023
Plan of Correction
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LIcensee will ensure gate is always closed.
Type B
Section Cited
CCR
102417(g)(9)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in which Licensee could not produce Emergency disaster plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/23/2023
Plan of Correction
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LIcensee will provide LPA a diaster plan via email no later than 6/23/23
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:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
4
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Document Has Been Signed on
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- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, and interview, the licensee did not comply with the section cited above in which Licensee stated she does not have a fire drill log, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/23/2023
Plan of Correction
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Licensee will conduct a fire drill within the next 30 days and will keep a log of fire drill. Licensee will email fire drill log to LPA.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in which she does not have any documents or signed forms for any of the assistnats she employs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/23/2023
Plan of Correction
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Licnesee will have assistants fill out all forms and documents needed to comply. LPA will conduct a visit to verify compliance.
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:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
5
of
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Document Has Been Signed on
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- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in which Licensee does not posess the correct CPR & 1st aid certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/23/2023
Plan of Correction
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4
LIcensee will enroll in a child/infant/adult CPR & 1st aid course. Licensee will email LPA a copy of certficate.
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in which licensee does not have Paren'ts Rights Poster posted in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/23/2023
Plan of Correction
1
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4
LPA provided Licensee a Personal Rights poster to post for parents. LPA will conduct a visit to verify compliance.
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:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
6
of
11
Document Has Been Signed on
05/24/2023 07:14 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in which Licensee could not produce immunization records for assistants, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/23/2023
Plan of Correction
1
2
3
4
Licensee will collect all needed documents and forms from all assistants. LPA will conduct a visit to verify compliance.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in which she did not immunization records for 18 of 18 children's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/23/2023
Plan of Correction
1
2
3
4
Licensee will collect required documents from all families enrolled. LPA will conduct a visit to verify compliance.
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:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 591-1072
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
7
of
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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
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
VISIT DATE:
05/24/2023
NARRATIVE
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page 2...
Cleaning agents, poison, and hazardous items were found to be accessible to children. Functioning smoke detector was observed but a carbon monoxide detector was not plugged in. LPA observed a 3-A-40-BC fire extinguisher. Sharp utensils are stored in a kitchen drawer; however, safety lock is faulty making it accessible to children. The licensee understands that she must ensure the safety locks are not broken. Toys appear to be safe and in working order. Licensee states there are no weapons in the home. The fireplace in the home has tempered glass and has a gate surrounding it. A gate is located at the bottom of the stairs; however, was left unlocked.
LPA walked the perimeter of the backyard and observed the right side of the fence was leaning towards neighbor’s yard. There’s a section of the fence that has loose boards due to the severe weather the area experienced. Licensee will work with neighbor to fix leaning fence and missing boards. Outside has plenty of age-appropriate toys, a trampoline and a large climbing structure. There are no bodies of water on the premises. Licensee was reminded to ensure backyard gate leading to the front yard is latched and closed. Licensee has a shed that was not secured with a combination or key lock.
Licensee could not produce a roster, fire drill, children’s files, or employees files. Licensee does not have correct CPR card. Licensee does not have to take mandated reporter training due to language barrier.
Licensee acknowledges that a Plan for Providing IMS must be submitted to the Department. 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) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at:
http://www.ada.gov/childqanda.htm
.
Continued on LIC809C...
SUPERVISOR'S NAME:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
9
of
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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
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
VISIT DATE:
05/24/2023
NARRATIVE
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page 3...
Licensee has 1 infant currently enrolled and was not aware that an (LIC9227) Individual Infant Sleeping Plan, for infants under 12 months and sleep logs for all infants in care under 24 months need to be maintained in children’s files. LPA discussed the safe sleep regulations with Licensee and provided the Child Care Licensing Safe Sleep webpage at
https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep
as an additional resource. LPA provided a sample of a sleep log.
LPA also informed Licensee, of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at
https://www.cpsc.gov/
and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. LPA encouraged Licensee to visit the department website at
WWW.CCLD.CA.GOV
for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.
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
.
LPA informed Licensee, Yali Fu, that this report dated 5/23/2023, documents
Type A citations
that are an immediate Health and Safety, or Personal Rights risk to persons in care. In addition,
Type B citation
s were issued that are a potential Health and Safety, or Personal Rights risk to persons in care.
A separate 809D is issued for each deficiency. Upon receipt of a Type A deficiency, licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. Licensee understands that all parents or authorized representatives of currently enrolled children must sign the LIC 9224 form and be available to the
SUPERVISOR'S NAME:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
Page:
10
of
11
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH
,
2525 NATOMAS PARK DR. STE 250
SACRAMENTO
,
CA
95833
FACILITY NAME:
FU, YALI
FACILITY NUMBER:
343621189
VISIT DATE:
05/24/2023
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Department for review. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed Acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.
An Exit interview was conducted, and the report was reviewed with Licensee, Yali Fu. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.
SUPERVISOR'S NAME:
Bettina Engelman
TELEPHONE:
(916) 263-5820
LICENSING EVALUATOR NAME:
Corina Beckby
TELEPHONE:
(916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
LIC809
(FAS) - (06/04)
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