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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416673
Report Date: 01/22/2025
Date Signed: 01/22/2025 06:55:00 PM

Document Has Been Signed on 01/22/2025 06:55 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:CHI, LEWISFACILITY NUMBER:
434416673
ADMINISTRATOR/
DIRECTOR:		LEWIS CHIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 930-2778
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 10DATE:
01/22/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:35 PM
MET WITH:Lewis ChiTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
NARRATIVE
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At 1:35PM, Licensing Program Analyst (LPA) Angela Luz and Mandeep Kaur were let into the facility by an Assistant Rosa Mary Garay to conduct an unannounced annual random inspection. Upon arrival, present for this inspection was two assistants(S1 &S4) with 10 children. The home was toured to conduct a Health and Safety Inspection with an assistant(S1). Days and hours of operation are from Monday-Friday 8AM-5:30PM.

At 01:53PM, Head teacher(S2) arrived at the facility.
At 02:12PM, Licensee, Lewis Chi arrived at the facility.

Facility:
The ON LIMIT AREAS are playrooms 1, 2, and 3, daycare bathroom, and backyard.
The OFF LIMIT AREAS are bedrooms 1-3, master bathroom, kitchen, washer/dryer area, storage area, garage, and side yard. The ISOLATION AREA is playroom 2.

The home is a single story home. LPAs observed two children(C1&C2) in playyards in offlimit bedroom #1. The home is neat and clean with heating and ventilation for safety and comfort. The outdoor play area is fully fenced. There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are no bodies of water. Licensee states that there are no firearms in the home. The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. LPA reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes.

***Page 1 of 4***
Belinda DevallTELEPHONE: (408) 324-2128
Angela LuzTELEPHONE: (408) 324-2148
DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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 11
Document Has Been Signed on 01/22/2025 06:55 PM - It Cannot Be Edited


Created By: Angela Luz On 01/22/2025 at 05:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CHI, LEWIS
FACILITY NUMBER: 434416673

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. LPAs observed side garage door and shed was closed, but not locked with sharp objects stored, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Deficiency was cleared during today's inspection: Licensee locked the side garage door and shed door was locked.
Type B
Section Cited
CCR
102425(a)(4)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (4) Mattresses shall be made specifically for the size crib or play yard in which they are placed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and interviews, the licensee did not comply with the section cited above. LPAs observed two children in the playyard where mattress is missing and Licensee stated that it's just the padding they use in the playyard that is smaller than the size of the playayard, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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By plan of correction due date, 01/29/2025, Licensee will submit the proof of Mattresses in the play yard specifically for the size of play yard in which they are placed to the department.
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:Belinda Devall
TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME:Angela Luz
TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 2 of 11
Document Has Been Signed on 01/22/2025 06:55 PM - It Cannot Be Edited


Created By: Angela Luz On 01/22/2025 at 05:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CHI, LEWIS
FACILITY NUMBER: 434416673

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. LPA Luz observed a cloth bag hanging on the side of one of the play yard, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/22/2025
Plan of Correction
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Deficiency was cleared during today's inspection.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and records review, the licensee did not comply with the section cited above. Licensee self admitted that they do not have infant sleep log to check on the infants every 15 minutes, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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By plan of correction due date, 02/05/2025, Licensee will submit the copy of the infant sleep log to check on the infants every 15 minutes.
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:Belinda Devall
TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME:Angela Luz
TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 11
Document Has Been Signed on 01/22/2025 06:55 PM - It Cannot Be Edited


Created By: Angela Luz On 01/22/2025 at 05:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CHI, LEWIS
FACILITY NUMBER: 434416673

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above. LPAs observed two children (C1&C2) in a bedroom#1 with the door closed, as child (C2) was taking a nap and Child (C1) was crying, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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By plan of correction due date, 01/29/2025, Licensee will submit the statement of understanding of Title 22 regulations section code: 102425(j)(5) and how he will adhere to the regulations in the future. Staff (S1) left the door open while a child(C2) was taking a nap.
Type B
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above where Staff (S4) is not associated to the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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By plan of correction due date 01/29/2025, Licensee will submit the proof of fingerprint clearance associated to the facility to the department.
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:Belinda Devall
TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME:Angela Luz
TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 01/22/2025 06:55 PM - It Cannot Be Edited


Created By: Angela Luz On 01/22/2025 at 05:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CHI, LEWIS
FACILITY NUMBER: 434416673

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and records review, the licensee did not comply with the section cited above. Licensee does not have current completion of certificate of CPR/First aid on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Lciensee has registered for pediatric CPR/first aid training for 01/25/25 and by plan of correction, due date, 01/29/2025, licensee will submit the proof of completion of pediatric CPR/First aid certificate to the department.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Belinda Devall
TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME:Angela Luz
TELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 11
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: CHI, LEWIS
FACILITY NUMBER: 434416673
VISIT DATE: 01/22/2025
NARRATIVE
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Care and Supervision: There are ample age-appropriate toys that appear to be safe and in good condition.

The play yards used for infant napping do not hinder entrance or exit to and from the space where infants are sleeping. LPAs observed mattresses in both playyard are small, therefore not made specifically made for the size of the play yard. Each infant’s bedding is used for them only and cleaned weekly or before use by another infant. LPA, Luz observed a loose object on a play yard while a child was in the playyard. Each infant under 12 months of age has an Individual Infant Sleeping Plan maintained in the file signed and dated by the infant’s authorized representative. Licensee was reminded of infant sleep checks every 15 minutes that notate any signs of distress are maintained in their file.

Licensee uses redirection as a form of discipline. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature.

Also, discussed with the Licensee was isolation of sick children, supervision of children, staffing ratio and capacity, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for an assistant/substitute.

Records: The Licensee CPR is expired. Licensee Mandated Reporter Training for Child Care Providers is current and expires 2/12/25. Licensee was reminded of Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. The Licensee conducts and documents fire and disaster drills every six months, last drill was on 10/16/24. All required forms are posted and visible for public review.

LPA Luz reviewed six (6) children files during today's inspection for the following records: Notification of Parents Rights(LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization records. Based on records review, two children (C1&C2) out of six(6) children are missing immunizations records, ID and emergency information and a child (C4) is missing Parents rights receipt(LIC 995).

***Page 2 of 4***
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Angela LuzTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
Page: 9 of 11
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: CHI, LEWIS
FACILITY NUMBER: 434416673
VISIT DATE: 01/22/2025
NARRATIVE
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LPA, Luz reviewed four (4) staff files for the following records: Employee rights(LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), and required training. Based on records review, Staff (S2) is missing immunization records. Staff(S4) has eligible fingerprint clearance but not associated to this facility.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee 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.

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/.

***Page 3 of 4***
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Angela LuzTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
Page: 10 of 11
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: CHI, LEWIS
FACILITY NUMBER: 434416673
VISIT DATE: 01/22/2025
NARRATIVE
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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.

During the exit interview, the Licensee Lewis Chi confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 1/21/25.

During today's inspection, seven Type B deficiencies are issued. Deficiencies are notated on attached 809-D and appeal rights were provided.

A notice of site visit was given and must remain posted for 30 days.


Exit interview conducted and report was reviewed with licensee Lewis Chi.

***Page 4 of 4 End of Report***
SUPERVISOR'S NAME: Belinda DevallTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Angela LuzTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
Page: 11 of 11