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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423598
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:31:24 PM

Document Has Been Signed on 08/22/2024 03:31 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:ITO, CHIHIROFACILITY NUMBER:
013423598
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
08/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Chihiro ItoTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 08/22/2024 at 11:45 PM Licensing Program Analysts (LPA's), Kareeca Sykes and Ashley Curry arrived at the home and conducted an unannounced annual/random inspection. LPA's met with licensee, Chihiro Ito, who granted inspection authority to tour the facility. Also present for the inspection was uncleared adult Moe Me. Licensee indicated that she was a volunteer. LPA's observed volunteer alone caring for a child.(See 809D). License was advised to have Moe Me fingerprinted. LPA's observed five (5) children in care consisting of three (3) infant and two (2) preschoolers. Licensee states there are currently 8 children enrolled. Children’s files were reviewed.

On- limit area: The children use bathroom located across from the kitchen, living room, bedroom #2 (across from the kitchen).


The off-limits areas will be inaccessible by closed and/or locked doors, safety gates, and safety locks as well as visual supervision.

The isolation area is in the living room.

The LPA's toured all areas used by children. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There are safe toys, play equipment, and materials observed for children. There were no stairs. There is a working telephone in the home. LPA's observed a fireplace in the living room that is barricaded and made inaccessible to children in care. All poisons, cleaning solutions, medications, and other items that pose a danger to children are inaccessible during this visit. The licensee does understand that poison must be in a locked cabinet/drawer or placed out of reach of children. The home is equipped with a fully charged 2A10BC fire extinguisher, working smoke alarm, and working carbon monoxide detector. Licensee states there are no firearms on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water. Licensee has current CPR and First Aid training which expires on August 13, 2026.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ITO, CHIHIRO
FACILITY NUMBER: 013423598
VISIT DATE: 08/22/2024
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LPA's observed and inspected sleeping equipment. All equipment meets the US Consumer Product Safety Commission standards. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months of age should be placed on their back for sleeping. The licensee was reminded that all infants up to 12 months of age shall have the LIC 9227 form placed in their file.

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.

LPA's 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.

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 informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: ITO, CHIHIRO
FACILITY NUMBER: 013423598
VISIT DATE: 08/22/2024
NARRATIVE
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During the exit interview the licensee, Chihiro Ito, confirmed that there are no Registered Sex Offenders living in the facility and LPA's completed the RSO profile in FAS.

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

Exit interview conducted, appeal rights were given, and report was reviewed with the licensee, Chihiro Ito.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2024 03:31 PM - It Cannot Be Edited


Created By: Ashley Curry On 08/22/2024 at 01:12 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: ITO, CHIHIRO
FACILITY NUMBER: 013423598

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring all volunteer/assistants, who are alone with day care children, have an eligible criminal background clearance, which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed Moe Me caring for a day child in the absence of the licensee.
POC Due Date: 08/29/2024
Plan of Correction
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By 08/29/2024 email LPA live scan receipt for Moe Me.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Monica Mathur
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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