434415484-9-13-2022-07-CC-SCOS-CJ8U29-20220913151134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415484
Report Date: 09/12/2022
Date Signed: 09/13/2022 03:11:41 PM

Document Has Been Signed on 09/13/2022 03:11 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	GONG, YAN		FACILITY NUMBER:	434415484
ADMINISTRATOR:	YAN GONG		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 449-5550
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95133
CAPACITY:	14	CENSUS: 5	DATE:	09/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Yan Gong		TIME COMPLETED:	11:55 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	Page 1 On September 12, 2022 Program Analysts (LPA) Stephanie Collins conducted an annual random inspection of the home. LPA met with Licensee, Yan Gong and explained the purpose of today's inspection. Present in the home were her two Assistants, Qiao,Jing and Medriz Chipres . There were 5 children in care during time of inspection. Days and hours of operation are Monday through Friday from 07:00 AM – 7:00 PM. Licensee understands the capacity options. There are (2) two adults residing in the home; The Licensee, and her husband ( Katung Chu) with their daughter. . A review of records shows that all individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Yan Gong 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 toured and observed the inside and outside home. The home is kept clean and orderly, with heating and ventilation for safety and comfort. Fireplaces and open face heaters are screened to prevent access by children. Fire extinguishers and smoke detectors meet state fire marshal standards. Where children less than five years old are in care, stairs are fenced and barricaded. The home provides safe toys, play equipment and materials. Facility has one or more functioning carbon monoxide detectors that meet the statutory requirements. The licensee is present in the home and ensures that children in care are supervised at all times. The licensee is observed maintaining capacity specified on the licenses. Each child has safe, healthful and comfortable accommodation, furnishing and equipment. Off limit area in the home is the up-stairs area of home. Backyard is fully fenced no bodies of water observed. Off limits area in backyard are sides of yard and storage bin. Licensee states there are no weapons or ammunition on the premises.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Stephanie Collins	TELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GONG, YAN	FACILITY NUMBER: 434415484
	VISIT DATE: 09/12/2022

NARRATIVE

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Licensee provides the child’ parent or representative with a copy of the Family Child Care Home notification of parent ‘ Rights.

Medication, cleaning products and similar items that can pose a danger to children if readily accessible are stored inaccessible to children. LPA reviewed the facility's roster and obtained a copy. Fire and disaster drills were last conducted and recorded on 6/10/2022 Licensee states that there are no weapons in the home. The backyard is fenced and is used for outdoor activities.
No open bodies of water observed. At least one person/ staff has current Pediatric CPR and First Aid expires on 03/2023. LPA observed that Licensee and her assistant have proof of immunity against Measles and Pertussis and Tuberculosis. Licensees’ assistant/staff have current AB1207 Mandated Reporter Training Certificate (s) completed date is 07/20/2022.

LPA reviewed 5 children’s files. Records reviewed include Parents' Rights, immunization, Identification and Emergency Information, and Consent for Emergency Medical Treatment, Family Child Care Home Notification of Parents' Rights, and Affidavit Regarding Liability Insurance.

Incidental Medical Services (IMS) policy was discussed. 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.htm

LPA reviewed with licensee, the LIC 311D, Forms/Records to Keep in Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

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SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Stephanie Collins	TELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GONG, YAN	FACILITY NUMBER: 434415484
	VISIT DATE: 09/12/2022

NARRATIVE

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Sleep

LPA discussed the safe sleep regulations with licensee Yan Gong 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.

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.

LPA referred the Licensee to the Department website: www.ccld.ca.gov for additional information.

No violations were observed during the inspection. Exit Interview was conducted, where this report, was discussed and reviewed with Licensee. A copy of this report was given to Licensee.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 314-5102
LICENSING EVALUATOR NAME: Stephanie Collins	TELEPHONE: (408) 334-8555
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC809 (FAS) - (06/04)

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