434416716-4-14-2021-07-CC-MMOO-C23QC7-20210414120240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416716
Report Date: 04/14/2021
Date Signed: 04/14/2021 12:03:18 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:	ZHANG, SIJIA		FACILITY NUMBER:	434416716
ADMINISTRATOR:	ZHANG, SIJIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 981-4915
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	14	CENSUS: 0	DATE:	04/14/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sijia Zhang		TIME COMPLETED:	12:00 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	On April 14, 2021 at 10:00 AM, Licensing Program Analyst (LPA) Marilou Monico conducted an announced prelicensing tele-inspection via Facetime in response to Applicant's request for a change of location application received by the Department. LPA met with Applicant, Sijia Zhang, and explained the purpose of today's tele-inspection. LPA notes that Applicant is currently licensed at 10441 Lansdale Avenue, Cupertino, CA 95014 (Facility number: 434415710). 10:00 AM - Application/Record Review: LPA observed the Applicant is the only person in the home during today's tele-inspection. The adults that reside in the home: Applicant and her husband The Applicant also has two minor children, ages 5 and 3 years, residing in the home. The Applicant resides in a one-storey, 3-bedroom, 2-bathroom house. Days and hours of operation will be Monday to Friday from 8:00 AM to 6:00 PM. The Applicant completed her Preventative Health and Safety Child Care Training including Nutrition. Applicant Lead Poisoning Prevention training was completed on March 20, 2021. The Applicant's CPR and First Aid certification is current, expires on April 3, 2023. Applicant's proof of completion of the Mandated Reporter Training for Child Care Workers (completed 04/13/2021) is on file. The Applicant rents the home and Property Owner/Landlord Consent (LIC 9149) and Property Owner/Landlord Notification (LIC 9151) forms as well as verification of control of property are on file. All individuals subject to a criminal record review 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. 10:10 AM - Physical Plant tour: There is a working telephone in the home (408) 981-4915. The home is clean and orderly, with heating and ventilation for safety and comfort. There is a fireplace in the dining room area and is barricaded. The off limit areas inside the home are: two bedrooms, dining room, kitchen, screen room, one bathroom, and garage. There are no off limit areas outside the home. 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 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: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ZHANG, SIJIA	FACILITY NUMBER: 434416716
	VISIT DATE: 04/14/2021

NARRATIVE

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Physical Plant tour (cont.): The Applicant has one fire extinguisher (2A10BC) in the home that is fully charged. The Applicant states that she does not have any firearms in the home. All cleaning compounds and medications are adequately stored (upper shelf in the garage) and inaccessible to the children. There are no poisons inside the home. The Applicant understands that baby walkers, baby bouncers, jumpers, and saucer chairs are not allowed in the home. The Applicant states that no one in the home smokes and she understands that smoking is prohibited in the home. The Applicant has a first aid kit in the home, which also has a thermometer and sufficient emergency supplies.

10:30 AM - Kitchen tour: The refrigerator and freezer in the home is clean. There are no sharp objects accessible to children. The kitchen area is gated. 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.

10:40 AM - Bathroom tour: The toilets and faucets are clean, safe, and operable. The bathtubs and showers are free of any hazards. Sharp objects and cleaning products are stored inaccessible to children.

10:50 AM - Outdoor tour: The backyard is fenced. There were no bodies of water observed.

11:00 AM - Document/Regulation Review: A Family Child Care Home packet with updated Licensing forms was emailed 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 (PIN 20-24-CCP), 6) Lead Flyer Requirement (PIN 20-01-CCP), and 7) Forms and Records to keep in your Family Child Care Home (LIC 311D).

Forms of discipline used by Applicant: time out (maximum 1 minute per year of age). 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.

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: ZHANG, SIJIA	FACILITY NUMBER: 434416716
	VISIT DATE: 04/14/2021

NARRATIVE

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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 he does not plan on administering medication to the day care children at this time.

11:10 AM - 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.

Fire clearance was granted on March 30, 2021.

The Applicant was informed that due to the current COVID-19 pandemic, today's report (Facility Evaluation Report - LIC 809) will be emailed to the Applicant (email: Daisy925520@hotmail.com). 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 large Family Child Care Home license will be approved upon completion of the following:

1) Acknowledgement of "receipt" of today's report has been received by LPA Monico
2) Applicant to notify analyst in writing when she plans to close her current license #434415710

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC809 (FAS) - (06/04)

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