013423325-8-3-2021-52-CC-MPRE-C5JRW3-20210803132227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013423325
Report Date: 08/03/2021
Date Signed: 08/03/2021 01:22:31 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/03/2021 01:22 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:	LI, QING YUN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 816-9681
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94545
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	08/03/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:42 PM
MET WITH:	Qing Yun Li		TIME COMPLETED:	01:25 PM

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On 8/03/2021 at 12:40am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Qing Yun Li for an unannounced annual inspection. Present during the inspection was Licensee Qing Yun Li. There were three (3) preschool children and two (2) infants during the inspection. The Licensee's home was 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 facility is a single-story home owned by the Licensee. 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.

At 1:00pm LPA obtained the facility roster and the children’s files. All files are complete. Licensee’s fire and disaster drill log is complete with the last drill logged 3/22/2021. All required forms are posted and visible for public view in the entry way. 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.

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 two (2) rabbits that live in a cage in the backyard. Licensee provided proof of immunization for pertussis, measles, and the flu shot.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

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: 08/03/2021

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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.

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 report was read and given to the Licensee for a signature. There are no deficiencies being cited today. This report shall remain on file for 3 years. Appeal Rights were provided and exit interview conducted. A Notice of Site visit was given and must be posted for 30 days.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021

LIC809 (FAS) - (06/04)

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