434411440-11-21-2019-07-CC-MMOO-BJ5QC4-20191121110232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411440
Report Date: 11/21/2019
Date Signed: 11/21/2019 11:02:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	HSU, JUI-CHUN SALLY		FACILITY NUMBER:	434411440
ADMINISTRATOR:	HSU, JUI-CHUN SALLY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 455-4684
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	14	CENSUS: 8	DATE:	11/21/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Jui-Chun Sally Hsu		TIME COMPLETED:	11:05 AM

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	Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Annual Random Inspection. LPA met with Licensee, Jui-Chun Sally Hsu, and explained the purpose of the inspection. Present during the inspection were 8 children in care, of whom three were infants. LPA observed that Licensee and two adult helpers, were present to provide care and supervision to the children The home’s operating days and hours are Monday through Friday from 08:30 AM to 06:00 PM. The home has a working telephone service. The License and Notification of Parents’ Rights, Emergency Disaster Plan, Earthquake Preparedness Checklist, were observed to be posted. The home was inspected inside and out. The home was clean and orderly. LPA did not observe flies, other insects, or rodents during the inspection. LPA observed sufficient materials, toys, and play equipment for the day care children. Bathroom used by children was observed to be clean and in operating condition. Food preparation area was clean. Areas inside the home that are Off Limit to day care children are three bedrooms, master bathroom, laundry room, entry closet, and garage. Off limit areas outdoor the home: locked storage shed located on the left side of the backyard. There were no bodies of water observed. Licensee stated that there were no weapons stored on the premises. A fully charged 3A40BC fire extinguisher was observed. Carbon monoxide and Smoke Detector were tested and proved to be functioning. Fire/Disaster Drill log recorded that the last drill was conducted on 10/10/19. Licensee stated that the day care does not provide transportation to the children. LPA reviewed and obtained a copy of the roster of children in care. Children’s files were reviewed, which included records of Identification and Emergency Information, Consent for Emergency Medical Treatment, Receipt for Parents' Rights Notice, Affidavit Regarding Liability Insurance, and Immunization. LPA reviewed licensee's assistant's files. Licensee's AB1207 Mandated Reporter Training expires on 09/17/2020 and her Pediatric CPR/1st Aid Certificate expires on 05/12/2020.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HSU, JUI-CHUN SALLY	FACILITY NUMBER: 434411440
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/21/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/12/2019 Section Cited	1 2 3 4 5 6 7	Employee and Volunteer Immunization - 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. This requirement is not met as evidenced by: Helper 1 & 2 are missing immunization in measles and pertussis. This poses a potential risk to health and safety to children in care.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HSU, JUI-CHUN SALLY	FACILITY NUMBER: 434411440
	VISIT DATE: 11/21/2019

NARRATIVE

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Licensee and her husband are the adults residing in the home. LPA reminded licensee that children living in the home who turn 18 years of age have 30 days from their birthday to obtain fingerprint clearances. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

LPA reviewed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Adoptions of new laws, pay annual fees etc.
Beginning January 1, 2019 AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPA reviewed and provided a copy of the “Lead Poisoning Facts Information Flyer” and Safe Sleep information to Licensee.

Incidental Medical Services (IMS) policy was discussed. Licensee stated that she currently does not have any children in care who requires IMS. 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) & link to Commonly Asked Questions and the ADA, available at:<http://www.ada.gov/childqanda.htm> .

As a result of this inspection, deficiency was cited on the following page:

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2019

LIC809 (FAS) - (06/04)

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