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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343622674
Report Date: 09/27/2021
Date Signed: 09/27/2021 10:02:01 AM

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:
09/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Chunying LuTIME COMPLETED:
10:10 AM
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On 9/27/21 Licensing Program Analyst (LPA) Fabiola Diaz conducted a case-management at the facility to inspect a weapon at the facility and clear a Plan of Correction (POC). A type A deficiency was cited on 9/24/21 due to the weapon and the ammunition being locked together in a safe in an off-limit area. On today’s date there were 7 children present supervised by licensee. Present was licensee's husband and visiting mother-in-law. LPA observed the mother-in-law to not have interactions with day care children.

On today's date (9/27/21) LPA observed the weapon and the ammunition to be locked separately in a safe in an off-limit area. LPA cleared the facility's POC for the Type A deficiency cited on 9/24/21.

No deficiencies were cited on today's date, and an exit interview was conducted with licensee. A Notice of Site Visit was provided and should remain posted for 30 days.

SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 263-2002
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021
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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