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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343621189
Report Date: 05/31/2023
Date Signed: 05/31/2023 01:23:37 PM


Document Has Been Signed on 05/31/2023 01:23 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, YALIFACILITY NUMBER:
343621189
ADMINISTRATOR:YALI FUFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 893-3063
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:14CENSUS: 12DATE:
05/31/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Fu, YaliTIME COMPLETED:
01:45 PM
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On May 31, 2023, Licensing Program Analysts (LPA's) Corina Beckby and Stacey Williams conducted a Plan of Correction Inspection. LPA's met with Licensee, Yali, Fu. Upon arrival LPA's observed 12 children supervised by Licensee and uncleared adult. This uncleared adult was also present during the inspection on May 24, 2023. Licensee was issued a civil penalty based on observation and lack of documentation for the uncleared adult assisting in care.

Licensee reported that the uncleared adult has not began the fingerprint clearance process. As of today, a failure to correct civil penalty is being assessed in the amount of $600 and will continue until the criminal record clearance is established for the uncleared adult.

Facility evaluation report was reviewed and discussed with Licensee, Yali Fu. Exit interview was conducted. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

During the visit, the Interpretation Services was used to translate in Licensee's home language of Mandarin, along with Licensee's adult son.
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina BeckbyTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023
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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