434411440-3-11-2025-07-CC-MMOO-DENQ8T-20250311115714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411440
Report Date: 03/11/2025
Date Signed: 03/11/2025 11:57:27 AM

Document Has Been Signed on 03/11/2025 11:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	HSU, JUI-CHUN SALLY		FACILITY NUMBER:	434411440
ADMINISTRATOR/ DIRECTOR:	HSU, JUI-CHUN SALLY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 455-4684
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 8	CENSUS: 7	DATE:	03/11/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:11 AM
MET WITH:	Jui-Chun Sally Hsu		TIME VISIT/ INSPECTION COMPLETED:	12:10 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 March 11, 2025 at 9:11 AM, Licensing Program Analyst (LPA), Marilou Monico, made an unannounced Annual Random Inspection. LPA met with Licensee, Jui-Chun Sally Hsu, and explained to her the nature of today's inspection. LPA was granted access to the home by the Licensee. The Licensee received the Entrance Checklist (LIC 126). Also present in the home were two adult helpers (S1 & S2) and seven (7) daycare children: 2 infants and 5 preschool age. LPA observed all required postings. The daycare is open Monday thru Friday from 8:30 AM to 6:00 PM. There are no active waivers or exceptions for this facility. Licensee stated that there are two adults residing in the home: herself and her husband. LPA obtained a copy of current children's roster. Fire/disaster drill was completed on October 15, 2024. LPA observed a fully charged 3A40BC fire extinguisher installed in the Play Room with no punched date or proof of purchase. LPA observed functioning smoke and carbon monoxide detectors and barricaded fireplace. Licensee stated 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 Licensee, Jui-Chun Sally Hsu, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated. Continuation on next pages:

Gladys Kuizon	TELEPHONE: (510) -56-5850
Marilou Monico	TELEPHONE: (408) 334-8549
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: HSU, JUI-CHUN SALLY	FACILITY NUMBER: 434411440
	VISIT DATE: 03/11/2025

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
26
27
28
29
30
31
32

Off limit areas inside the home: three bedrooms, master bathroom, laundry room, entry closet, and garage. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other items that are dangerous to children were stored inaccessible. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. Off limit areas outdoor: locked storage shed. No bodies of water were observed.

LPA reviewed eight (8) children's files 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), sleep log for children under 2 years old, and Immunization Records.

LPA reviewed two (2) helper's files for the following records: Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunizations, and TB test. S2 is missing immunization in measles. Licensee has the required immunizations and current Pediatric CPR/First Aid certifications with an expiration date of April 27, 2026. Licensee's Mandated Reporter Training expires on January 5, 2026. LPA reminded licensee that Mandated Reporter training must be renewed by all staff every 2 years.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.
Continuation on next pages:

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: HSU, JUI-CHUN SALLY	FACILITY NUMBER: 434411440
	VISIT DATE: 03/11/2025

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
26
27
28
29
30
31
32

Licensee, Jui-Chun Sally Hsu, was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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

During the exit interview, the Licensee, Jui-Chun Sally Hsu, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

As a result of this inspection, Type B deficiencies were cited on the following page.

A Notice of Site Visit was given to Licensee, Jui-Chun Sally Hsu, and must remain posted for 30 days.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) -56-5850
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/11/2025 11:57 AM - 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
SAN JOSE CC RO, 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

102417(g)(1)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, there is a fully charged 3A40BC fire extinguisher installed in the Play Room, however it does not have a punched date or proof of purchase. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/18/2025
	Plan of Correction
1 2 3 4	Licensee states that she will purchase a required size fire extinguisher and will submit photo and proof of purchase by 03/18/25.

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, Licensee's helper (S2) is missing immunization in pertussis which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/11/2025
	Plan of Correction
1 2 3 4	Licensee states that she will submit proof of immunization in pertussis for S2 by 04/11/25.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Gladys Kuizon	TELEPHONE: (510) -56-5850
Marilou Monico	TELEPHONE: (408) 334-8549
	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4