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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622674
Report Date: 07/28/2021
Date Signed: 07/28/2021 05:47:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:LU, CHUNYINGFACILITY NUMBER:
343622674
ADMINISTRATOR:LU, CHUNYINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 843-4335
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:14CENSUS: 7DATE:
07/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Chunying LuTIME COMPLETED:
04:35 PM
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On today's date 7/28/21 during a tele-inspection, Licensing Program Analyst (LPA) Fabiola Diaz observed 7 children at the facility, of which some were napping. Licensee showed LPA an infant sitting on a napping matt. Licensee explained the infant does not sleep with pillows, but sleeps with (and licensee held up a stuffed animal). LPA discussed Safe Sleep regulations with licensee and e-mailed licensee PIN 20-24-CCP. A Technical Violation note was assessed on today's date.

An Exit Interview was conducted. A copy of this report was e-mailed to the licensee. In lieu of a signature due to COVID-19, LPA Diaz requested that the licensee acknowledge receipt of this report via e-mail. Licensee may also provide LPA with a signed copy of this report if able to do so.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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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