013423325-8-1-2023-52-CC-MPRE-CUATQF-20230801145551

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013423325
Report Date: 08/01/2023
Date Signed: 08/01/2023 02:56:07 PM

Document Has Been Signed on 08/01/2023 02:56 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: 12	CENSUS: 12	DATE:	08/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:37 PM
MET WITH:	Qin Yun Li		TIME COMPLETED:	02:53 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 8/1/2023 at 12:37pm Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Qing Yun Li for a Required – 1 Year Inspection. Present during the inspection was the Licensee, her helper XiaoYun Lan, three (3) infants and nine (9) preschool age children. Licensee lives in the home with her husband (who is currently deployed), and their nine (9) year old son. The facility operates 8:00am – 6:00pm, Monday – Friday. ON LIMITS AREA: Living Room, Hallway Bathroom, 1^st Bedroom on the Right side of the Hallway, Kitchen, Dining Room and Backyard OFF LIMITS AREA: Master Bedroom and Bathroom, 2^nd Bedroom and Garage ISOLATION AREA: On-Limit Bedroom The facility is a single-story home owned by the Licensee. The inside of the home was observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee stated that she provides all food for the children. All food that is brought from the children’s home will be properly labeled and stored. All off limit areas are made inaccessible with gates, locks, and closed doors. Licensee stated she does not transport children. There are no pets and no firearms in the home. There is one (1) fully charged 2A10BC fire extinguisher in the garage. There is one (1) working smoke detector in the kitchen and hallway and one (1) carbon monoxide detector in the hallway. The home is equipped with central heat and plenty of windows and fans for proper ventilation. The fireplace in the dining area is blocked by furniture making it inaccessible to the children in care. All cribs, play yards and napping equipment are free from defects and in good condition. LPA observed a thick string with two toys hanging above one of the empty cribs. LPA informed Licensee that nothing is to be hanging above the crib. Licensee immediately removed the string and the toys from the crib.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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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Document Has Been Signed on 08/01/2023 02:56 PM - It Cannot Be Edited

Created By: Morgan Pringle On 08/01/2023 at 01:58 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: LI, QING YUN	FACILITY NUMBER: 013423325
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onrecord review and interview the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	Licensee will provide parent of the infant in care with LIC9227 and ensure that it is completed by POC date. Licensee will send LPA a copy of the completed form as well. Licensee will ensure that all children uner 12 months old have a completed LIC9227 in the child's file.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Jason Jang

LICENSING EVALUATOR NAME:

Morgan Pringle

LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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: 08/01/2023

NARRATIVE

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Licensee uses highchairs and tables for eating that are free from defects and in good condition. The backyard is fully fenced, clean, in good condition, with ample age-appropriate materials for the children.

Licensee’s Health and Safety training has been completed and EMSA approved Pediatric CPR & First Aid is complete and expires 1/15/2025. Licensee’s Mandated Reporter training is complete and expires 5/1/2025. All required forms are posted and visible for public view in the living room. Fire/Disaster drills have been completed with the last drill logged 3/16/2023. All adults living and working in the home have obtained a criminal record clearance. LPA obtained a sample of the children’s files, the facility files and facility roster. Through record review it was found that two (2) of the six (6) children’s files reviewed needed updated immunization records. Licensee’s helper was also missing Mandated Reporter training as well as immunization record for Mmr, Tdap, TB and the Flu. One (1) infant under twelve (12) months old was missing LIC9227 from file.

Deficiencies cited during LPA’s inspection
· One (1) infant under twelve (12) months old missing LIC9227 from file

Licensee was reminded that California law requires Licensees to report unusual incidents and/or injuries to children in care, to the child's parents, and to the Department within 24 hours by phone, fax, or email. Within seven (7) days from the incident, Licensee’s must submit the Unusual Incident/Injury form (LIC 624B) to the Department. Licensee was reminded that any structural changes or additions to the home must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting https://mandatedreporterca.com/. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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: 08/01/2023

NARRATIVE

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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 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.

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

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

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-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.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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: 08/01/2023

NARRATIVE

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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

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.

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

Exit interview conducted and report was reviewed with the Licensee Qing Yun Li.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

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