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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 03:32:34 PM

Document Has Been Signed on 08/22/2024 03:32 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:Case Management - Licensee InitiatedUNANNOUNCEDTIME 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 11:45AM Licensing Program Analysts (LPA's) Kareeca Sykes and Ashley Curry met with Licensee Chihiro Ito for an Unannounced Licensee Initiated Case Management Visit. Licensee submitted an increase of capacity application. Also present during the inspection was an uncleared adult, Moe Me, and (5) children in care consisting three (3) infants and two (2) preschoolers. Licensee’s home was toured for a health and safety inspection. The facility plans to operate 8:30AM - 4:00PM, Monday - Thursday.

ON LIMITS AREA: Living room, Dining Room, Kitchen, Bedroom #2 (Across from kitchen), bathroom, and Backyard.

OFF LIMITS AREA: Garage, Bedroom #1 (Across from dining room).

ISOLATION AREA: On the sofa in the living room away from other children in care.

The facility is a two (2) bedroom and one (1) bathroom home. The inside of the home is observed to be neat, clean with age appropriate materials for the children. During today's visit all toxins, cleaning products, medications and hazardous materials were observed to be in inaccessible areas. All off limit areas in the home will be made inaccessible with safety gate, closed doors, and locks. LPA did not observe any harmful bodies of water in or around the home. Licensee stated there are no pets and no firearms in the home.

Approved fire clearance received on 05/30/2024.

Increase of capacity has been approved and is effective as of today 08/22/2024.

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: Sherelle Johnson
LICENSING EVALUATOR NAME: Kareeca Sykes
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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