434414374-1-8-2020-07-CC-YHUG-BKMR5Q-20200108114332

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434414374
Report Date: 01/08/2020
Date Signed: 01/08/2020 11:43:37 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:	LIN, HAIYAN		FACILITY NUMBER:	434414374
ADMINISTRATOR:	LIN, HAIYAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(469) 307-6534
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95124
CAPACITY:	14	CENSUS: 12	DATE:	01/08/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Haiyan Lin		TIME COMPLETED:	11:50 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) Oscar Huang met with Licensee Haiyan Lin for an unannounced annual/random inspection. LPA explained the nature of today’s inspection to Licensee. LPA also observed two adult assistants, Fang Liu & Yanez Fuentes and 12 preschool day care children in the home during today's inspection. Days and hours of operation are Monday to Friday, 8:30am to 6:30pm. The adults that reside in the home are Licensee, her husband, and her parents' in-law. A review of staff records on today indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also 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. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, Licensee shall immediately remove the individual and prevent them from returning to the home or having contact with children in care. LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home appears clean and orderly, with heating and ventilation for safety and comfort of the children. Temperature was measured at 70 degree F by thermostat on the wall. LPA observed no baby walker, bouncers, excer-saucers, jumpers etc. on the premises. LPA observed no stairs inside the home. The main area of the home is used for the day care are a new addition room with bathroom LPA observed a barricaded fireplace. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher, a working smoke detector, and a functioning carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit were the main house including 4 bedrooms, 2 bathrooms, living room, dining room, kitchen and garage. LPA observed a fenced backyard and no bodies of water. LPA observed a locked storage shed in the fenced off area. Off limit areas outside the home: left side yards and the backyard where the storage shed is. Licensee owns the house, and has child care liability insurance with DCI. Facility Evaluation Report dated 01/08/2020 to be continued on next page:

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

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: LIN, HAIYAN	FACILITY NUMBER: 434414374
	VISIT DATE: 01/08/2020

NARRATIVE

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Facility Evaluation Report dated 01/08/2020 to be continued from previous page:
LPA observed Licensee and the helpers have current CPR and First Aid certification on 04/2021. LPA observed a current roster of the children and a fire and disaster drills log which is to be done at least once every six months. The last drills were conducted on 12/19/2019. LPA reviewed 12 children files. Immunization records are maintained and up-to-date, and immunization records are updated in form PM 286. LPA observed Notification of Parents’ Rights is in each child’s file.

Supervision of children was discussed with Licensee, and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options. Licensee states that she does not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time.

LPA discussed SB 792 Immunization Requirement with Licensee. LPA observed appropriate records for immunization against measles, pertussis, and influenza for Licensee and the helpers in file. Incidental Medical Services (IMS) were discussed with Licensee. Licensee is not providing IMS 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.

LPA discussed Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. The training web site is available at: https://mandatedreporterca.com/ Licensing Forms, Title 22 Regulations, Resources & Information, Quarterly Updates, Videos can be obtained through the internet at http://www.ccld.ca.gov. LPA observed one helper has completed her training on 08/09/2018 and her certification is on file. Licensee and her another helper requested to be exempt from training until a Chinese version becomes available.

No Deficiency was cited. Exit interview conducted with Licensee. A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2020

LIC809 (FAS) - (06/04)

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