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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423832
Report Date: 10/11/2022
Date Signed: 10/11/2022 10:44:07 AM

Document Has Been Signed on 10/11/2022 10:44 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:XI, NAFACILITY NUMBER:
013423832
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
10/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
07:50 AM
MET WITH:Na Xi TIME COMPLETED:
10:50 AM
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On 10/11/2022 Licensing Program Analyst(LPA), Arminder Singh conducted an announced Pre-licensing Inspection. LPA met with the Applicant, Na Xi and fingerprint cleared Husband, Wenhan Kuo. Applicant resides in the home with her Husband and underage child.

Applicant applied for a Small Family Child Care Home with capacity for 8 children. Days and hours of operation will be Monday through Friday from 8:00 AM - 6:00 PM. Applicant has current Pediatric cardiopulmonary resuscitation (CPR) and First Aid certification. Applicant owns the home. Applicant has provided proof of ownership of home. Applicant has a working telephone in the home.(510-735-5713)

LPA toured the indoor space of the home with the Applicant.. The home is a two story home. The home consists of three bedrooms, three and half bathrooms, living room (classroom), dining area, kitchen, and backyard.

IN USE AREAS: The living room (classroom), dining room, two bathrooms located on first floor (one bathroom is full bath and other is a half bathroom), bedroom located on first floor which is located towards the back of the home, and outdoor play area.

OFF LIMIT AREAS: The kitchen and entire second floor which has two bedrooms, two bathrooms, and laundry room. The second floor is made inaccessible by a gate/barricade.

Outdoor Area: Outdoor play area is fully fenced. The outdoor play area has a padded surface. The outdoor play area does have a locked shed towards the back of the outdoor play area. Applicant understands that the shed shall be made inaccessible when children are outdoors. The applicant understands 100% visual supervision is required.

CONTINUED ON NEXT PAGE
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: XI, NA
FACILITY NUMBER: 013423832
VISIT DATE: 10/11/2022
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The home is sanitary, safe and orderly, with central heating and ventilation for safety and comfort. LPA observed: fully charged 2A10BC fire extinguisher, working smoke and carbon monoxide detectors all over the home. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets and out of reach of children. LPA reminded Applicants that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes. Applicants states there are no pets in the home. Applicants states there are no firearms and ammunition stored in the home.


Applicants understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children (bedroom on first floor), supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire drills must be practiced once every six months and documented.

Applicants was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: XI, NA
FACILITY NUMBER: 013423832
VISIT DATE: 10/11/2022
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LPA discussed the safe sleep regulations with applicant 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 applicant 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: http://www.ada.gov/childqanda.htm



Exit interview conducted and report was reviewed with the applicant. 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 platform.

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.

This facility is recommended for licensing effective 10/11/2022.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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