434416716-4-6-2022-07-CC-MMOO-CD8RD7-20220406125530

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416716
Report Date: 04/06/2022
Date Signed: 04/06/2022 05:54:55 PM

Document Has Been Signed on 04/06/2022 05:54 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
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: 12	DATE:	04/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Sijia Zhang		TIME COMPLETED:	01:10 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), Marilou Monico, met with Licensee, Sijia Zhang, for an unannounced Required - 1 Year Inspection. Also present in the home were licensee's husband, two adult helpers, and 12 daycare children including four infants and eight preschool age. LPA toured the home with Licensee. LPA observed all required posted materials. Days and hours of operation for the facility are Monday – Friday, 8:00 AM- 6:00 PM. There are no active waivers or exceptions for this facility. Licensee states that there are three adults residing in the home: herself, her husband, and her mom (helper). Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated. LPA reviewed and obtained copy of facility roster (LIC9040). Fire/disaster drill was conducted on December 1, 2021. LPA observed a fully charged 2A10BC fire extinguisher, glass covered fireplace, and functioning smoke and carbon monoxide detectors. Licensee states that she does not currently have any children in care who require Incidental Medical Services and does not administer medication at this time. Licensee states that there are no weapons or firearms in the home. Incidental Medical Services (IMS) policy was discussed. 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 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 Continuation on next pages:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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: 04/06/2022

NARRATIVE

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Indoor licensed areas of the facility were inspected by LPA today and observed to be clean, orderly, and safe for the day care children. Off limit areas in the home: 2 bedrooms, dining room, kitchen, one bathroom, screen room, and garage. LPA observed sufficient age-appropriate materials, toys, and play equipment in the facility. Furniture, such as tables, chairs, and shelves are in good condition and safe for children. The floors were clean and free of tripping hazards. Drinking water is readily available for children in the facility via sippy cups and bottles. The children's bathroom is clean, sanitary, and operable. The home has a working telephone which is (408) 981-4915.

The outdoor licensed areas of the home were inspected and observed to be fenced in. There were no bodies of water observed.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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.

Twelve (12) children’s files were reviewed during todays inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Affidavit Regarding Liability Insurance (LIC 282). Licensee carries daycare insurance.

Two (2) staff files were reviewed for the following records: Criminal Record Statement (LIC 508), Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), TB test, immunization in measles, pertussis, and flu, and Mandated Reporter Training. Licensee has Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and flu shot. The Licensee has Mandated Reporter Training that expires on April 13, 2023. Licensee's CPR/First-Aid expires on April 3, 2023. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years.
Continuation on next page:

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

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: 04/06/2022

NARRATIVE

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Supervision of children was discussed with the Licensee and she understands that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Sijia Zhang.

As a result of todays inspection, there were no deficiencies cited.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Marilou Monico	TELEPHONE: (408) 334-8549
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022

LIC809 (FAS) - (06/04)

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