<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700117
Report Date: 04/14/2022
Date Signed: 04/14/2022 11:49:41 AM


Document Has Been Signed on 04/14/2022 11:49 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:LEE, LINAFACILITY NUMBER:
015700117
ADMINISTRATOR:LEE, LINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 678-9284
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY:14CENSUS: 12DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lina LeeTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On April 14th, 2022 @ 9:15AM, Licensing Program Analyst (LPA) April Wright and Jyoti Saini arrived for an unannounced Annual/Random Inspection and met with Licensee Lina Lee. Present for this inspection were four 12 day-care children, 1 infant, 9 preschool, 2 school-age and the licensee's fingerprint cleared assistant Patricia Antenor- Cruz. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 9:00am to 5:00pm.

The home is two story single-family home which is neat and clean, with heating and ventilation for safety and comfort. The stairway has a child safety gate in place. Toxins, medicines, and hazardous items were inaccessible during today's inspection. There is a fully charged 2A10BC fire extinguisher, working carbon monoxide and smoke detectors, telephone, and first aid kit. There is a fireplace with a screen and glass doors in the living room area. The fireplace is not used and has a small bookcase for storage of children's toys placed in front of it. Per applicant, there are no firearms in the home

ON LIMIT Areas: include downstairs family room, living room, dining room, 1/2 bathroom, and outside backyard. The backyard area has outdoor grass carpet, five foot perimeter fencing (and child fencing to prevent children from wandering off the outdoor grass carpet and play area. There and ample children's toys for play. The outdoor play area is fenced and is free from defects and dangerous conditions. There were ample age appropriate toys that were observed to be safe and in good condition. There are no pools, hot tubs, or other bodies of water accessible to children.



OFF LIMITS Areas: include kitchen downstairs and all the upstairs area are made inaccessible by child gates, including the staircase leading to the upstairs, and garage. The kitchen has a child safety gate and has child locks on cupboards. All knives are kept up high, there are no other hazardous cleaning materials stored in the kitchen.
See LIC 809-C for continuance
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: April WrightTELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LEE, LINA
FACILITY NUMBER: 015700117
VISIT DATE: 04/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Records Review: LPA Wright requested and reviewed the files of for 10 children in care. C1 -C3 children's files were missing immunization records. Licensee contacted parents to have them send records to Licensee as soon as possible. Remaining children's files contained Immunization, Parent's Rights, and Medical Consent forms. The facility roster was reviewed, and copies were obtained. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 1/10/2022. The licensee's Health and Safety training is completed, and CPR and First Aid certificate is current and expires 3/2024. The licensee has completed mandated reporter training on 3/2/2022. The licensee is in ratio today and All required form are posted and visible for public review.

Incidental Medical Services (IMS) policy was discussed. No IMS services are being administered at this facility. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

California Law requires Child Care Centers licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained, and fire/disaster drill every six months must be documented.

The licensee is reminded any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. The licensee was provided information regarding effects of Lead Exposure and testing requirements (Assembly Bill 2370) See LIC 809-C for continuance

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: April WrightTELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LEE, LINA
FACILITY NUMBER: 015700117
VISIT DATE: 04/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA Wright discussed the Safe Sleep regulations with licensee and discussed Child Care Licensing Safe Sleep web page 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.

Licensee was reminded that all adults 18 and over, 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 childcare center. 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. All forms can be downloaded at www.ccld.ca.gov

The licensee did receive a technical violation for Safe Sleep practices and 2 Technical advisories for Infant Sleep plan.

There are no deficiencies cited. A notice of site visit was given and must remain posted 30 days. Exit interview conducted and report was review with Licensee Lina Lee.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: April WrightTELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3