<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421535
Report Date: 08/12/2021
Date Signed: 08/12/2021 12:12:58 PM

Document Has Been Signed on 08/12/2021 12:12 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SHI, WENYANFACILITY NUMBER:
013421535
ADMINISTRATOR:SHI, WENYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 260-5837
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
08/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Wenyan ShiTIME COMPLETED:
12:30 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 08/12/2021 at 10:00 AM Licensing Program Analyst (LPA) Arminder Singh met with Licensee Wenyan Shi for an unannounced random annual inspection. There are 12 children present today. Present during inspection was Licensee, Assistant, and Father. Days and hours of operation are Mon - Friday, 8:30 AM to 5:30 PM.

The home is a one story home with a garage. The home consists of a kitchen, two living rooms, family room, four bedrooms (1 is converted into dance studio), two bathrooms, and a backyard.

The ON LIMIT AREAS are the two living rooms, two bedrooms (next to bathroom), bathroom and backyard. The children are escorted through the kitchen and family room into the backyard.

The remainder of the home is OFF LIMITS which will be inaccessible by closed and/or
locked doors, safety gates and visual supervision.

There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs, or any other bodies of water.
The home has a fully charged 3A40BC fire extinguisher, working smoke detector, and carbon monoxide detector. The home has centralized heating. The home does have a fireplace that is located in the living room that is not being used and is made inaccessible and blocked off. Licensee states there are no firearms in the home. Licensee does not have any pets. Fire/disaster drills are conducted every six months and are logged. Last drill was conducted on 07/09//2021. The living room is the isolation room. Licensee does have a fully stocked first aid kit.

At 11:45AM six (6) children's records were reviewed by the LPA and files are complete. Licensee has current Pediatric CPR and First Aid certificates and expire on 06/18/2023. LPA has obtained a copy of the current children's roster.
Please see LIC 809 C for additional information
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2021
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SHI, WENYAN
FACILITY NUMBER: 013421535
VISIT DATE: 08/12/2021
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
Outdoor Yard: The outdoor play area is free from defects or dangerous conditions and is fully fenced. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies or hazardous materials and toxins are kept out of the reach of children. The outdoor play area is fully fenced and has sandbox that is clean and free of litter. Licensees understand that 100% supervision is required at all times.


This facility is not providing Incidental Medical Services - IMS at this time. LPA discussed IMS services and the requirement to create a plan of operation. Specifics on the plan can be found in the family child care home evaluator manual.

REMINDERS/RESOURCES
· Criminal Background Clearance: All assistants, volunteers, frequent adult visitors (adults are individuals 18 years of age or older) must be fingerprint cleared and associated to the facility prior to be in the presence of children in care. Failure to comply, requires an immediate civil penalty of $100 to $3000 per person, per incident.

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.

Beginning January 1, 2019 AB 2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families.
"Mandated Reporter" training for CA Child Care Providers that all staff are required to complete as of January 1, 2018. [Starting May 2019, both General Training followed by Child Care Providers Training is required to be taken]. The website for the online training is: http://www.mandatedreporterca.com/training/childcare.htm.

CONTINUED ON NEXT PAGE
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SHI, WENYAN
FACILITY NUMBER: 013421535
VISIT DATE: 08/12/2021
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
· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

· NEW LAW: Safe Sleep Regulations: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep

· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse.

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

Website for provider resources:
http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

childcareadvocatesprogram@dss.ca.gov

In the areas that were evaluated, no regulatory violations were observed.

At 12:15 PM Exit Interview was conducted, where this report was reviewed and discussed with Licensee. Report was signed by the Licensee confirming receipt of documents.

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.

END OF REPORT
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3