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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416270
Report Date: 06/10/2020
Date Signed: 06/10/2020 11:54:43 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:LIU, QINGFACILITY NUMBER:
434416270
ADMINISTRATOR:LIU, QINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 679-3449
CITY:SAN JOSESTATE: CAZIP CODE:
95130
CAPACITY:14CENSUS: 2DATE:
06/10/2020
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Qing LiuTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Oscar Huang conducted an announced case management tele-inspection via video conference call (FaceTime) with Qing Liu, Licensee. The purpose of today's tele-inspection is to conduct an inspection in response to licensee's change location request. LPA noted that Licensee currently has an active large FCCH license, #434414760, located at 3883 Payne Avenue, San Jose, Ca 95117. According to Licensee that both homes are owned by her parents-in-law, they are exchanging homes due to her son will be going to school in this coming fall and this home is located at a better school district.

LPA observed both her children at home. Days and hours of operation are Monday to Friday, 8:00am to 6:30pm. The adults that reside in the home are Licensee and her husband. LPA advised Licensee that her two children will be accounted for her capacity when presented at home during her business hours. Licensee stated that her facility is currently close due to COVID-19 pandemic, and she does not have a plan to reopen.

Licensee agreed to give LPA a tour of the indoor/outdoor via FaceTime during today's tele-inspection. The entire home was inspected for health and safety hazards. The house is an one story building. The main area of the home is used for the day care are family room, playroom, and bathroom #1. LPA observed screened fireplace. Off limit areas inside the home: kitchen, dining room, living room, bedroom #1 & #2, Master bathroom, bathroom #2, and garage. LPA observed a fully charged 3A40BC fire extinguisher, at least one functioning carbon dioxide and one smoke detectors. fenced backyard, and no bodies of water. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. Licensee states that there are no weapons or pets in the home. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA did not observe drop side cribs, and baby walkers, bouncers, excer-saucers, jumpers etc. and remind licensee that no smoke in not allowed in Family Child Care Homes. Licensee was advised to keep temperature within 68-85 degrees.


Facility Evaluation Report dated 06/10/2020 to be continued on next page:
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: LIU, QING
FACILITY NUMBER: 434416270
VISIT DATE: 06/10/2020
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Facility Evaluation Report dated 06/10/2020 to be continued from previous page:
Licensee stated she will carry the child care liability insurance once the license is approved at this location. LPA advised licensee that before the insurance is obtained, she will need to obtain signed Affidavit Regarding Liability Insurance For Family Child Care Home from parents of children in care and keep it on each child's file. LPA observed Licensee has current CPR and First Aid certification expiring 11/2021. LPA also observed licensee's proof of Preventative Health and Safety Child Care Training on file, taken on 03/05/2016, which includes an hour of nutrition class. Licensee requested to be exempted until a Chinese version material becomes available due to her limited English.

LPA observed appropriate records for immunization against measles, pertussis, and influenza for Licensee and on file. Incidental Medical Services (IMS) were discussed with Licensee. Licensee is not providing IMS at this time. If in the future any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

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. 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.

Supervision of children was discussed with Licensee, and she understands that they 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 they do not transport children via vehicle but they understand that children cannot be left in parked vehicles unattended at any time. LPA reviewed safe sleep policies for the infants with the Licensee and provided Licensee "A Child Care Provider's Guide to Safe Sleep” document. More information can be founded at http://www.cdss.ca.gov/inforesources/Child-Care-Licensing.
Facility Evaluation Report dated 06/10/2020 to be continued on next page:
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: LIU, QING
FACILITY NUMBER: 434416270
VISIT DATE: 06/10/2020
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Facility Evaluation Report dated 06/10/2020 to be continued from previous page:

A fire clearance was granted for capacity of 14 (Large FCCH) from the San Jose Fire Department was received on 03/10/2020. Rooms accessible to children include: Playroom, Bathroom #1/2, Family Room, Backyard. Room Off Limits include: Bedrooms # 1& #2, Master Bedroom, Garage, Kitchen, Dining Room & Living Room.

The licensee was informed that due to the current COVID-19 pandemic and "Shelter In Place" Order, today's report (Facility Evaluation Report - LIC 809, two LIC809-Cs) will be emailed to the licensee's email address at bilingualdaycaressj@gmail.com with "Read Receipt" notification. The licensee understands that her response to the email is considered an acknowledgement of "receipt" of today's report.

LPA conducted an exit interview with Licensee, and advised her that her large FCCH license at this new location is now pending upon the following items and the management approval:



1. Update Floor Plan Sketch showing all doors & windows.
2. Original Statement Acknowledging Requirement to Report Child Abuse - LIC9108 (including second page with signature & date).
3. Proof of immunization record for Influenzae vaccine or decline statement.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020
LIC809 (FAS) - (06/04)
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