414004259-6-14-2022-05-CC-WLYY-CFDS8Z-20220614133954

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 414004259
Report Date: 06/14/2022
Date Signed: 06/14/2022 01:40:42 PM

Document Has Been Signed on 06/14/2022 01:40 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	CHEN, YA		FACILITY NUMBER:	414004259
ADMINISTRATOR:	CHEN, YA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 345-0181
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	14	CENSUS: 8	DATE:	06/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Ya Chen		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On June 14, 2022 at approximately 10:45am, Licensing Program Analyst (LPA) Winnie Ly conducted an Unannounced Required - 1 Year Visit to this family child care home and met with Licensee Ya Chen. Purpose of visit was explained. Present during the visit were Licensee and an assistant caring for 4 infant age children and 4 preschool age children. Day Care Areas to be used for day care are the enclosed patio (listed on the facility sketch as kids room) and the hall bathroom. The front yard will be used for outdoor activities. The Off Limit Areas will be the 3 bedrooms, master bathroom, garage and backyard. The family room, kitchen and living room will be used to transition children from the enclosed patio to the hall bathroom. Licensee’s CPR expires 08/2022. Completed Child Abuse Mandated Reporter Training: LPA observed the home is clean orderly and properly ventilated. LPA also observed a 2A10BC Fire extinguisher, operable smoke detectors and carbon monoxide. There are no Fireplace or bodies of water in the home. Electrical outlets have child protective covers in place making them inaccessible to children. Chemical, detergents, cleaning compounds, medications, and other items of this nature are made inaccessible to children. Kitchen/Bathroom cabinets/drawers have child protective locks in place making all sharp objects or toxic house hold items inaccessible to children. First aid supplies are available for children. Facility conducts fire drills/earthquake drills on 05/03/2022 and was properly logged. Disciplinary policy was discussed with Licensee today. Home has age appropriate toys and equipment available for the children in care. At 11:45am, LPA reviewed children's files, infant's file does not have LIC 9227 Infant Sleeping Plan on file. Infant without an LIC 9227 on file poses a potential risk to children in care. The deficiency was being cited based on LPA Ly’s record review in accordance with the California Code of Regulations, Title 22, see LIC 809D. CONTINUED>>>

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie Ly	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHEN, YA	FACILITY NUMBER: 414004259
	VISIT DATE: 06/14/2022

NARRATIVE

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This family child care home provides Incidental medical Services-IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. 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.

Licensee was also informed that as of September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

LPA discussed Child Abuse Mandated Reporter Training AB1207 with Licensee. As of January 1, 2018 all staff will be required to complete Child Abuse Mandated Reporter Training every two years. The training can be obtained online at www.mandatedreporterca.com.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. 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.

An exit interview was conducted and Plans of Corrections (POC) were developed and reviewed with Licensee. A copy of this report and appeal rights were discussed and will be emailed to Licensee whose signature on this form confirm have read the reports. Notice of Site Visit will also be emailed to licensee. Licensee was inform Notice of Site Visit to remain posted for 30 days upon receipt. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm

SUPERVISOR'S NAME: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie Ly	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 06/14/2022 01:40 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CHEN, YA	FACILITY NUMBER: 414004259
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1out of 1 infant which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2022
	Plan of Correction
1 2 3 4	Licensee must work with family to have LIC 9227 fill out. Licensee send proof of LIC 9227 to LPA by due date 06/28/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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: Garfield Leung	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Winnie Ly	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

LIC809 (FAS) - (06/04)

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