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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423598
Report Date: 11/12/2021
Date Signed: 11/12/2021 02:06:53 PM

Document Has Been Signed on 11/12/2021 02:06 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:ITO, CHIHIROFACILITY NUMBER:
013423598
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
11/12/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:33 AM
MET WITH:Chihiro ItoTIME COMPLETED:
02:30 PM
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On 11/12/2021 at 11:33am Licensing Program Analyst (LPA) Catherine Fernandes met with Licensee Chihiro Ito for an Unannounced Annual Inspection. Present during the inspection was the Licensee, her finger print cleared husband, two preschoolers and two infants in care. The home was toured for a health and safety inspection. The facility operates from 9:00am – 4:30pm Monday – Friday.

The home is a single story house that consists of two bedrooms and two bathrooms. The inside of the home was observed to be neat and clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas.

ON LIMITS AREA: Living Room, Dining Area, the bathroom next to the kitchen, the kitchen, the patio and the backyard.
OFF LIMITS AREA: the bedrooms and the bathroom in the master.
ISOLATION AREA: Is the front room next to the front door

The home has a fully charged 2A10BC fire extinguisher under the kitchen sink, a working smoke detector in the dining room and a functioning carbon monoxide detector located in the kitchen. The Licensee has provided a working telephone number and email address. The Licensee's Health and Safety training was completed and CPR and First Aid certificate is current and expires on 07/12/2022. The heater vents are located on the floor and were observed to be covered. The fireplace is blocked off with a wooden gate preventing access by children. Per Licensee, there are no firearms in the home. LPA Fernandes reviewed staff and children's files. . All required forms are posted and visible for public view by the front door. LPA obtained the children’s files and the facility roster. The fire drill log was available and the last fire drill was conducted on 5/12/2020, Licensee stated they are conducting drill this month.

Report continues on 809C.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ITO, CHIHIRO
FACILITY NUMBER: 013423598
VISIT DATE: 11/12/2021
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm Licensee is providing IMS at this time.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/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 web page 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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

A notice of site visit was given and must remain posted for 30 days.
Exit interview conducted
Report and Appeal Right were provided

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Catherine Fernandes
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC809 (FAS) - (06/04)
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