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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423598
Report Date: 01/23/2024
Date Signed: 01/23/2024 11:39:33 AM

Document Has Been Signed on 01/23/2024 11:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 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: 8CENSUS: 0DATE:
01/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Chihiro ItoTIME COMPLETED:
11:39 AM
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On 1/23/24 at 11:10am Licensing Program Analyst (LPA) Ashley Akinleye arrived at the facility for a case management visit. LPA was met by licensee Chihiro Ito. Licensee would like to request active status for facility.

LPA toured the home with licensee Chihiro Ito for a health and safety inspection. The home is a single story house with two bedrooms, two bathrooms, a backyard and basement. The on limits include the living room, one bathroom, one bed room, kitchen and backyard. The off limits areas include one bed room and one bathroom. LPA observed all the required forms to be posted. LPA observed the home to be neat and clean with heating and cooling for ventilation.

LPA did not observe any hazards or dangerous items that would pose a potential harm to children.

LPA reviewed facility file and requested LIC 9149 and LIC 9151 from licensee.

Licensee signed LIC 9151 and LIC9149 was signed by husband who is the owner of the home.

Licensee's husband provided tax statements as proof of control of property.

Exit interview conducted with licensee Chihiro Ito.

A notice of site visit was provided to licensee to post for 30 days.

Appeal rights were provided to licensee for review.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Akinleye
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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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