434415484-3-6-2024-07-CC-SCHN-D34TK7-20240306134727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415484
Report Date: 03/06/2024
Date Signed: 03/06/2024 01:47:50 PM

Document Has Been Signed on 03/06/2024 01:47 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 CC RO, 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: 12	DATE:	03/06/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Yan Gong		TIME COMPLETED:	02:30 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	Page 1. On 3/6/24 Licensing Program Analyst (LPA) Sheena Chin met with Licensee, Yan Gong, for an unannounced annual inspection. LPA explained the nature of today’s inspection to Licensee. Present during today’s inspection were the licensee, 2 helpers and 12 children in the facility. Days and hours of operation are Monday to Friday, 8:30am to 6:00pm. The licensee stated that the facility did not accept children under 12 months but accepted children with medical needs. The licensee stated that the facility stored EpiPen for one child in care. The adults that reside in the home are licensee and her husband. The licensee stated the ownership of the home. Observation LPA observed that required postings were posted. LPA, along with the licensee toured the inside and outside of the home. The facility has a full charged fire extinguisher, 3A40BC. Smoke detectors are working properly. The off-limit areas inside in the home are the second floor and garage. All disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible. LPA observed that there are toys for children and each water bottle had a label of a child’s name. LPA conducted CARE Tools for this annual inspection, which include Physical Plant, Care and Supervision, Facility Administration, Records, Staffing Ratio and Capacity, Personnel Rights for compliance with all licensing statutes, regulations, and interim licensing Standards, and results were documented on the tool. continue to page 2.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena Chin	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GONG, YAN	FACILITY NUMBER: 434415484
	VISIT DATE: 03/06/2024

NARRATIVE

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Page 2.
Records review
The Licensee has current CPR and First Aid certifications expiring 4/2/25 . The Licensee has the child abuse training certificate, expiring 9/12/24. LPA reviewed the fire and disaster drills log which shall be done at least once every six months. The last drills were conducted on 7/14/23. The facility did not comply with fire-drill regulations.

LPA reviewed children and staff files. Immunization records are maintained and updated. LPA observed Notification of Parents’ Rights is in each child’s file. The facility used Daily Connect App to document 15 min. sleeping checks for infants under 2 years old.

The facility did not maintain the immunization records for two helpers, who were hired less than 2 months. LPA advised the licensee to have helpers complete the mandated reporter training within the first 90 days that they were employed at the facility. S1 had background clearance but was not associated with this facility. The licensee stated that the LIC9182, Criminal Background Clearance Transfer Request, was sent to the San Jose Regional Office in late January and the facility has not heard from the office yet. The licensee submitted the LIC9182 to LPA for the background transfer.

During today’s inspection, all adults present or residing in the home have criminal record clearances required by the Department. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Discussion

Supervision of children was discussed with Licensee, who 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.

continue to page 3.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena Chin	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GONG, YAN	FACILITY NUMBER: 434415484
	VISIT DATE: 03/06/2024

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Page 3.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

The Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Deficiency
Regulatory violations were observed during the inspection. Therefore, citations were issued.

Further questions
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.

Exit
During the exit interview, the Licensee, Yan Gong, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
Exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were reviewed and discussed with Licensee, Yan Gong.
Notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena Chin	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/06/2024 01:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GONG, YAN	FACILITY NUMBER: 434415484
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. The facility did not conduct fire drills every 6 months, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	The licensee stated that a fire drill will be held this week and send LPA a copy of fire drill.

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. The facility did not maintain documentations of the required immunizations for two helpers, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	The licensee will send LPA the copy of the immunization records for the two helpers.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena Chin	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024

LIC809 (FAS) - (06/04)

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