434415392-3-5-2020-07-CC-YHUG-BMEQAF-20200305105951

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415392
Report Date: 03/05/2020
Date Signed: 03/05/2020 10:59:56 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:	SHANG, ANN I		FACILITY NUMBER:	434415392
ADMINISTRATOR:	ANN I SHANG		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 992-5576
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94085
CAPACITY:	14	CENSUS: 10	DATE:	03/05/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Ann Shang		TIME COMPLETED:	11:15 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, Ann Shang for an unannounced annual inspection. LPA explained the nature of today’s inspection to Licensee. Present were two finger print clearance adult assistants and 10 day care children (2 infants & 8 preschool children) in the home during today's inspection. Days and hours of operation are Monday to Friday, 8:30am to 6:00pm. The adult that reside in the home is Licensee and her adult son. 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 received all staff criminal background clearance transfer requests on site. 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. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period. 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 72 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 kitchen, living room, dinning room, bedroom 1, and a 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 in top cabinets inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher, a working smoke detector in living room and each of the bedrooms, and a functioning carbon monoxide detector in dinning room. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: bedroom 2 & 3, and the garage. LPA observed a fenced backyard and no bodies of water. Facility Evaluation Report dated 03/05/2020 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: 03/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020

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: SHANG, ANN I	FACILITY NUMBER: 434415392
	VISIT DATE: 03/05/2020

NARRATIVE

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Facility Evaluation Report dated 03/05/2020 to be continued from previous page:
Off limit areas outside the home: both gated side yards. Licensee owns the house and carry child care liability insurance under DCI. LPA observed Licensee has current CPR and First Aid certification expiring 04/2021. The adult assistant's CPR and First Aid certifications are current and expire on 01/20/2021. 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 02/15/2020. LPA reviewed 12 children files that are required by the regulation including iImmunization records are maintained and up-to-date and 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 her assistants on 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. The following information regarding ADA was provided: US Department of Justice (USDOJ) 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.htmLicensee will submit a plan of operation for IMS if in the future they provide any IMS to a child in care. 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: http://www.mandatedreporterca.com/training/childcare.htm LPA observed licensee's certification completed on 04/03/2018, and helpers completed her training on 2/2/2020 & 2/20/2020 respectively.
No Deficiency was cited. Exit interview conducted with Licensee. A NOTICE OF SITE VISIT WAS ISSUED, AND MUST REMAIN POSTED WITH TYPE A DEFICIENCIES NEAR THE ENTRANCE 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: 03/05/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2020

LIC809 (FAS) - (06/04)

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