434411440-11-30-2021-07-CC-MMOO-C99VZC-20211130155231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411440
Report Date: 11/30/2021
Date Signed: 11/30/2021 03:52:50 PM

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: 7	DATE:	11/30/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:53 PM
MET WITH:	Jui-Chun Sally Hsu		TIME COMPLETED:	04:05 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	Licensing Program Analyst (LPA), Marilou Monico, met with Licensee, Jui-Chun Sally Hsu, for an unannounced Required - 1 Year Inspection. LPA was granted access to the home by the Licensee and toured the indoor and outdoor areas. Also present in the home were licensee's adult helper and seven (7) daycare children including one (1) infant and six (6) preschool age. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Friday, 8:30 AM to 6:00 PM. The facility has a waiver on file to allow the fireplace to remain un-screened, however, the waiver is no longer active. LPA observed a barricaded fireplace in the family room. Licensee states that the adults that reside in the home are herself and her husband. Licensee and her husband have Criminal Background Check Clearance, Tuberculosis (TB) Clearance, and signed Criminal Record Statements (LIC508). Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated. LPA observed a current facility roster (LIC9040). Fire/disaster drill was conducted on June 14, 2021. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detector, and working carbon monoxide detector. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Licensee states that there are no weapons or firearms in the home. Incidental Medical Services (IMS) policy was discussed. 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 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

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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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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: 11/30/2021

NARRATIVE

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Indoor areas of the facility were inspected today and observed to be clean, orderly, and safe for the day care children. Off limit areas in the home: three bedrooms, master bathroom, laundry room, entry closet, and garage. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the home via plastic cups. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 455-4684. Off limit areas outside the home: locked storage shed.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://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.

Seven (7) children’s files (1 infant and 6 preschool age) were reviewed during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282) and Immunization Records (PM 286/CDPH 286).

Licensee and her adult helper have Mandated Reporter Training with an expiration date of August 29, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years, website: www.mandatedreporterca.com. Assembly Bill (AB) 633 was discussed with licensee. Licensee and her helper have current Pediatric CPR/First Aid certifications however, the class was taken on-line. LPA advised licensee to take the In-person Pediatric CPR/First Aid class and submit proof of completion to Licensing by January 30, 2022. Per record review, licensee's adult helper (Helper #1) is missing immunization in measles and pertussis.

Continuation on next page:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

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
	VISIT DATE: 11/30/2021

NARRATIVE

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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.
Supervision of children was discussed with the Licensee. The Licensee states that she does not transport any day care children. LPA reminded Licensee that if she decides to transport children, children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Jui-Chun Sally Hsu.

As a result of today's inspection, deficiency was cited on the following page:

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: 11/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee's adult helper (Helper #1) is missing immunization in measles and pertussis. This poses a potential risk to the health, safety or personal rights of children in care.
	POC Due Date: 01/30/2022
	Plan of Correction
1 2 3 4	Licensee states she will submit proof of immunization in measles and pertussis for her helper by 01/30/22.

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: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021

LIC809 (FAS) - (06/04)

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