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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700004
Report Date: 05/31/2023
Date Signed: 05/31/2023 01:04:14 PM

Document Has Been Signed on 05/31/2023 01:04 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 SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:YANG, YANGFACILITY NUMBER:
015700004
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
05/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Yang Yang- LicenseeTIME COMPLETED:
01:10 PM
NARRATIVE
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On 5/31/23 at 10:45am, Licensing Program Analyst (LPA) Briana Plumboy conducted an unannounced Case Management Inspection with Licensee for the purpose to increase capacity. Present for the inspection was licensees mother Yulan Zhang who does not have a fingerprint clearance and lives in the home, and 6 children in care (2 whom are licensees). The home was toured with the licensee to conduct a health and safety inspection.
Today, licensee is being cited for her mother not having a fingerprint clearance. She has the option by closing of business today to choose one of the following options, or the department may take further action against the license.
1) Change her status from Active to Inactive Status until Yulan Zhang obtains a fingerprint clearance or moves; or
2) Surrender her license; or
3) Yulan Zhang must move out the home until she obtains a fingerprint clearance
Licensee stated she will go on inactive status beginning tomorrow 6/1/23 until 6/27/23 until her mother returns to China or retains a fingerprint clearance (Licensee is aware whichever occurs first she may contact LPA Plumboy/ CCLD for an inspection to revert her status back to active).
On 05/24/23, a fire clearance was granted to facility #015700004 by Alameda County Fire Department. All documents have been received for the increase of capacity application but an increase in capacity cannot be granted at this time due to an unfingerprinted adult living in the home.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident.
See 809-C for continuance
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2023
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 SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: YANG, YANG
FACILITY NUMBER: 015700004
VISIT DATE: 05/31/2023
NARRATIVE
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As of 5/31/23, this home is PENDING increase of capacity. See 809D for deficiency. The attached Type A deficiency is cited today. Upon receipt, licensee shall post for 30 days and provide copies of this licensing report to parent/guardians of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 Acknowledgement of Receipt of Licensing Reports should be signed by guardians and placed in each child’s file. A notice of site visit was provided, and the licensee was reminded to have it posted for 30 days. This entire report has been read to the Licensee by LPA Plumboy. The licensee is aware the signature on this report confirm receipt of these documents. LPA asked the licensee if the licensee had any questions pertaining to any aspects including, but not limited to, any part of this report and of the documents given to the licensee, and per licensee, there are no further questions at this time. Licensee is aware at anytime she can reach out to LPA Plumboy or CCLD. An exit interview was conducted, and appeal rights provided.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/31/2023 01:04 PM - It Cannot Be Edited


Created By: Briana Plumboy On 05/31/2023 at 12:29 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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: YANG, YANG
FACILITY NUMBER: 015700004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2023
Section Cited
CCR
102370(d)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee stated she will change her status to inactive status until 6/27/23 which is when her mother returns to China, or obtain a criminal record clearance for her.
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TODAY AN IMMEDIATE CIVIL PENALTY OF $500 IS ASSESSED BECAUSE 1 ADULT LIVING IN THE HOME IS NOT CLEARED OR ASSOCIATED ASSOCIATED TO THIS FACILITY. By an adult not being cleared and associated, it poses an immediate health and safety risk to children in care.
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$500 Civil Penalty assessed.
Lic.9224 shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months.

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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:Wynn Norona
LICENSING EVALUATOR NAME:Briana Plumboy
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2023


LIC809 (FAS) - (06/04)
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