434416472-1-6-2021-07-CC-MSMS-BWZUF5-20210106143207

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416472
Report Date: 01/06/2021
Date Signed: 01/06/2021 02:33:48 PM

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:	LU, LI		FACILITY NUMBER:	434416472
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 1	DATE:	01/06/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Li Lu		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Mel Matos conducted an announced prelicensing tele-inspection via video conference call (via FaceTime) with Li Lu, Applicant. The purpose of today's tele-inspection: address the Application for a Small Family Child Care Home license that the Applicant submitted to the Department on December 7, 2020. Application/Record Review: The Applicant, Applicant's spouse (Xingchang Jiang), and Applicant's 8 year old daughter was present in the home during today's tele-inspection. The Applicant and her spouse are the adults residing in the home. The Applicant also has a minor child (daughter - age 8 years) residing in the home. Days and hours of operation will be Monday to Friday from 8:00 AM to 6:00 PM. The Applicant completed the Preventative Health and Safety Child Care Training on December 6, 2020 and a copy of the certification is on file. The Applicant completed the CPR and First Aid training on October 5, 2019 and certifications are on file. Updated vaccinations (including flu vaccine) and proof of completion of the Mandated Reporter Training for Child Care Workers (completed on 12/13/2020) are on file. The Applicant owns the home and a copy of the grant deed verifying control of property is on file. All individuals subject to a criminal record review (Applicant & Applicant's spouse) have obtained a criminal record and child abuse index clearances prior to today's tele-inspection. The Applicant agreed to give LPA a tour of the home (indoor/outdoor) via FaceTime during today's tele-inspection. Physical Plant tour: There is a working telephone in the home (cell #650-245-8170). The home is clean and orderly, with heating/air conditioning, and ventilation for safety & comfort. All window blind cords are inaccessible to children. There are no stairs inside the home. There are no wall heaters or fireplace units in the home. The off limit areas inside the home are: 3 bedrooms & one 2 car garage. The off limit areas outside the home: locked storage shed in the backyard, right side area of the backyard, and right side area of the locked storage shed. The off limit areas outside the home are inaccessible to children. There are safe and age appropriate toys, play equipment, and materials for the children in the home. The Applicant has a designated area in the home (dining room) where a child(ren) can be isolated if exhibiting signs of illness. The home has working smoke/carbon monoxide detectors in the home (tested by the Applicant during today's tele-inspection).

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

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: LU, LI	FACILITY NUMBER: 434416472
	VISIT DATE: 01/06/2021

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
26
27
28
29
30
31
32

Physical Plant tour (cont.): The Applicant has one fully charged fire extinguisher (2A10BC) inside the home. The Applicant does not have any pets or firearms in the home. All cleaning compounds and medications are adequately stored (high cabinets) and inaccessible to children. There are no poisons inside the home. The Applicant states that she does not have any baby walkers in the home. The Applicant understands that baby walkers are not allowed in the day care. The Applicant states that she does not have any baby bouncers, jumpers, saucer chairs, and trampolines in the home. The Applicant understands that inclined sleepers are not allowed in the home. The Applicant understands that high chairs are to be used only for eating purposes. The Applicant states that she and her spouse do not smoke and she understands that smoking is prohibited in the home. The Applicant has a first aid kit in the home, with sufficient emergency supplies. The Applicant does not have a touchless thermometer in the home.

Kitchen tour: The refrigerator and freezer in the home is clean. There are no sharp utensils, cleaning products, lighters/matches, or open bottles of alcohol accessible to children. The Applicant understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

Bathroom tour: The bathroom toilet and faucet is clean, safe, and operable. The bathtub and shower is free of any hazards. All shampoos, soap, medication, mouthwash, perfumes, razors, cleaning products, air fresheners, and nail polish/remover are inaccessible to the children.

Outdoor tour: The outdoor backyard area of the home is fenced, safe, and secure for the children. LPA observed a play structure in the backyard that is safe and secure to the ground. The Applicant does not have resilient materials (padding) surrounding the play structure. The Applicant has an air conditioner unit in the backyard that needs to be barricaded or covered. There are no bodies of water in the backyard.

Document/Regulation Review: A Family Child Care Home packet with updated Licensing forms was mailed to the Applicant prior to today's tele-inspection and the Applicant acknowledged receipt of the packet. Documents from the packet, including but not limited to the following were discussed and reviewed with the Applicant: 1) Child Care Facility Roster (LIC 9140) must be complete and current at all times, 2) Fire/disaster drills must be practiced at least once every 6 months and documented on the fire/disaster drill log provided to the Applicant, 3) Posting requirements - Parent's Rights (PUB 394), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), and Facility License, 4) Staffing & Ratio - capacity/ratio limitations handout, 5) Safe Sleep Regulations, 6) Lead Flyer Requirement (PIN 20-01-CCP), 7) Forms and Records to keep in your Family Child Care Home (LIC 311D), & 8) COVID-19 required postings/resource/self-assessment information.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

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: LU, LI	FACILITY NUMBER: 434416472
	VISIT DATE: 01/06/2021

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
26
27
28
29
30
31
32

Forms of discipline used by Applicant: time-out. The Applicant understands that children's personal rights should not be violated; including no corporal punishment, supervision of children, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed with the Applicant during today's tele-inspection.

Incidental Medical Services (IMS) policy was discussed with the Applicant during today's tele-inspection. 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.htm. The Applicant states that she does not plan on administering IMS services (including inhaler or EpiPen) to the day care children at this time.

Notification requirements/civil penalty: LPA discussed the requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected. LPA reminded the Applicant 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.

The Applicant was informed that due to the current COVID-19 pandemic and "Shelter In Place" Order, today's report (Facility Evaluation Report - LIC 809) will be emailed to the Applicant (email: lilylu0801@gmail.com) with "Read Receipt" notification. The Applicant understands that her response to the email is considered an acknowledgement of "receipt" of today's report.

LPA conducted an exit interview and advised the Applicant that a small Family Child Care Home license will be approved upon completion of the following:

1) Applicant has barricaded or covered the air conditioner unit, located in the backyard.
2) Applicant has installed resilient materials (padding) surrounding the play structure.
3) Applicant has purchased a touchless thermometer for the day care.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 01/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3