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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421118
Report Date: 08/07/2024
Date Signed: 08/07/2024 12:24:45 PM

Document Has Been Signed on 08/07/2024 12:24 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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:NA, NANCYFACILITY NUMBER:
013421118
ADMINISTRATOR/
DIRECTOR:		NA, NANCYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 579-6044
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
08/07/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Nancy NaTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On 8/7/2024 at 10:20AM Licensing Program Analyst (LPA) Jaleesa Jackson met with Licensee Nancy Na for an Annual/Random visit. Present during the inspection was the Licensee, her brother/assistant, her adult daughter, her husband, her 2 minor sons, 6 preschool aged children, and 3 infants. All adults living, working and/or volunteering in the home have obtained a criminal record clearance. The facility operates 7:30AM – 5:30PM, Monday - Friday.

ON LIMITS AREA: Living Room, Kitchen, Dining Area, Downstairs Bathroom, Downstairs Bedroom (infant nap room) and Backyard

OFF LIMITS AREA: Entire 2nd floor, Media Room/Family Room (behind on-limits bedroom), Garage, and both sides of the backyard

ISOLATION AREA: Kitchen

The facility is a two-story home owned by the Licensee. The inside of the home is observed to have age-appropriate materials for the children. During today's inspection all toxins, cleaning products, personal medications, and hazardous materials were observed to be in inaccessible areas. All off-limit areas were made inaccessible with locks, gates, and closed doors. Licensee has stated that there are no firearms and a dog in the home. The home has a fully charged 2A10BC fire extinguisher. There is a working combination smoke/carbon monoxide detector in the home. The home is equipped with central heat and air for proper ventilation.

Continued 809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: NA, NANCY
FACILITY NUMBER: 013421118
VISIT DATE: 08/07/2024
NARRATIVE
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 Licensee provides all food for the children. All food that is brought from the children’s home will be properly labeled and stored. The staircase is gated making it and the second floor inaccessible to the children in care. Licensee stated she does not transport children. The backyard is fully fenced with age-appropriate materials for the children in care. Both sides of the backyard are made inaccessible with gates. There are 2 sheds in the off limits areas. LPA did not observe any harmful bodies of water in or around the home.

LPA reviewed 9 children's files and found them to be complete. Licensee's and her assistant's Pediatric CPR and First Aid training is complete and expires 5/2026. Licensee’s and her assistant's Mandated Reporter training is complete and expire 6/22/2025. All required forms are posted and visible for public view in the living room. Licensee’s fire drill log is complete with the last drill logged 4/17/2024.

There were no deficiencies cited on today's inspection.

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.

Continued 809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
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
OAKLAND SOUTH CC RO, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: NA, NANCY
FACILITY NUMBER: 013421118
VISIT DATE: 08/07/2024
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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/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE Nancy Na, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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

Exit interview conducted and report was reviewed with the licensee Nancy Na.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jaleesa Jackson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
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