434414215-6-24-2022-52-CC-MESA-CFPMR4-20220624094942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414215
Report Date: 06/24/2022
Date Signed: 06/24/2022 09:49:55 AM

Document Has Been Signed on 06/24/2022 09:49 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	CHAN, KAREN HIU		FACILITY NUMBER:	434414215
ADMINISTRATOR:	CHAN, KAREN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 594-8242
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	14	CENSUS: 0	DATE:	06/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Karen Hiu Chan		TIME COMPLETED:	10:00 AM

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On Friday, June 24, 2022 9:03 AM, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced required one (1) year visit. LPA met with the Licensee Karen Chan explained the nature of site visit. Present on this visit was the Licensee's Assistant and NO children in care at the moment. The facility operates from Monday to Friday 8am to 6pm.

The home was toured to conduct a Health and Safety Inspection. The home is a single family home. The home is neat and clean with heating and ventilation for safety and comfort. The on limit areas are the living room, hallway bathroom and the fenced backyard patio. The off limit area are the all bedrooms and the kitchen. The designated isolation area when a child becomes ill is the TV room. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. No firearms in the facility.
The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector and working telephone. Licensee does not transport children.

The licensee CPR and First Aid certificate and expires on May 2024. The licensee completed the Mandated Reporter General Training and Child Care Providers training online at https://mandatedreporterca.com/Licensees have records of Measles and Pertussis immunization, Influenza vaccination and TB clearance. LPA reminded Licensee that only the Influenza vaccination can be decline with a written declination.

Children’s files were reviewed, which included records of receipt for Parents' Rights Notice, Identification and Emergency Information, Consent for Emergency Medical Treatment form, and Immunization.

LPA discussed PIN 22-10 CCP and PIN 20-24 CCP.

See 809 C......

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel Estoesta	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: CHAN, KAREN HIU	FACILITY NUMBER: 434414215
	VISIT DATE: 06/24/2022

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Continuation.....

Licensee does not own the premises and advised to maintain the forms LIC 282 AFFIDAVIT REGARDING LIABILITY INSURANCE, LIC 9149 PROPERTY OWNER/LANDLORD CONSENT FAMILY CHILD CARE HOME and LIC 9151 PROPERTY OWNER/LANDLORD NOTIFICATION FAMILY CHILD CARE HOME in the facility file.

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/inspection-process.

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 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 [facility representative] 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.

There are no deficiencies cited on this visit.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Karen Hiu Chan.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel Estoesta	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC809 (FAS) - (06/04)

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