434411440-1-30-2023-07-CC-MMOO-CNKT6D-20230130132658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411440
Report Date: 01/30/2023
Date Signed: 01/30/2023 01:27:03 PM

Document Has Been Signed on 01/30/2023 01:27 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, 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: 9	DATE:	01/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:41 AM
MET WITH:	Jui-Chun Sally Hsu		TIME COMPLETED:	01:40 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. Also present in the home were licensee's two adult assistants and nine (9) daycare children including three (3) infants and six (6) preschool age. All required posted materials were posted by entrance. 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. Per Licensee, the adults residing in the home are herself and her husband. LPA observed a current children's roster (LIC9040). Copy of children's roster was obtained during the inspection. Fire/disaster drill was conducted on December 10, 2022. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke and carbon monoxide detectors, and barricaded fireplace. Licensee states that there are no weapons or firearms in the home. Incidental Medical Services (IMS) policy was discussed. Licensee states that she is not planning to administer any medication at this time. 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 LPA reminded licensee 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. 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: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

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: 01/30/2023

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Off limit areas in 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 facility. 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. No bodies of water were observed.

Nine (9) children’s files 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), Immunization Records. and Notification of Additional Children in Care (LIC 9150).

LPA reviewed two helper's files for the following records: Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), Employee Rights (LIC 9052), required immunizations and TB test, and Mandated Reporter Training. Licensee's Mandated Reporter Training expires on August 29, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years. Licensee has current Pediatric CPR/First Aid certification with an expiration date of April 9, 2024.

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

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

As a result of today's inspection, there were no deficiencies cited.

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: 01/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2023

LIC809 (FAS) - (06/04)

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