013423325-7-2-2021-52-CC-MPRE-C4JTKG-20210702144755

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013423325
Report Date: 07/02/2021
Date Signed: 07/02/2021 02:48:00 PM

Document Has Been Signed on 07/02/2021 02:48 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME:	LI, QING YUN		FACILITY NUMBER:	013423325
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	07/02/2021
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Qing Yun Li		TIME COMPLETED:	02:47 PM

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On 7/02/2021 at 2:00pm Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Qing Yun Li for an announced case management inspection for a capacity increase. Present during the inspection was Licensee Qing Yun Li. There were four (4) preschool children and one (1) infant during the inspection. The Licensee's home was then toured for a health and safety inspection. The facility plans to operate from 8:00am – 6:00pm, Monday – Friday.

ON LIMITS AREA: Living Room. Bathroom, Bedroom, Kitchen, Dining Room and Backyard

OFF LIMITS AREA: Garage and 2 bedrooms
ISOLATION AREA: Bedroom

The home has gained a fire clearance on 6/25/2021 from the Hayward Fire Department.

The facility is a single-story home owned by the Licensee. The home consists of a kitchen, dining room, Living room, master bedroom with attached bathroom, guest bathroom, two other bedrooms and a garage and backyard.

The inside of the home and backyard is observed to be neat, clean with ample age appropriate materials for the children that are safe and clean. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas.

The home has a fully charged 2A10BC fire extinguisher in the garage, one (1) working smoke detector in the kitchen and the hallway. One (1) carbon monoxide detector in the hallway as well. The Licensee's Health and Safety training has been completed and CPR and First Aid certificate is current expiring on 7/11/2022 and Mandated Reporter training expires on 2/28/2023. Continued on 809-C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: LI, QING YUN	FACILITY NUMBER: 013423325
	VISIT DATE: 07/02/2021

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The home is equipped with working heat and ample windows that provide proper ventilation. Per Licensee, there are no firearms in the home. The Licensee has four (4) rabbits that live in a cage in the backyard. Licensee provided proof of immunization for pertussis, measles, and the flu shot.

Licensee was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed the applicant that all forms can be downloaded at www.ccld.ca.gov. Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Incidental Medical Services (IMS) policy was discussed as well. Licensee was reminded that when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.
Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.

This home has been approved for the capacity increase on 7/02/2021.

This report shall remain on file for 3 years. Appeal Rights were provided and exit interview conducted.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 07/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2021

LIC809 (FAS) - (06/04)

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