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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700356
Report Date: 06/08/2022
Date Signed: 06/08/2022 10:51:48 AM

Document Has Been Signed on 06/08/2022 10:51 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:WEN, QINFACILITY NUMBER:
015700356
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/08/2022
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Qin WenTIME COMPLETED:
11:10 AM
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On 06/08/2022, at 9:00AM, Licensing Program Analyst Kelly Phan, met with applicant Qin Wen for an announced case management visit for her relocation change from 4387 Romilly Way Fremont, CA 94536 (facility number #01341964) to 39672 Bruning Street, Fremont CA 94538. Presented during today's health and safety inspection was just the applicant. Per applicant, she has two fingerprinted and associated adult daughters but does not resides with her and her fingerprinted and associated ex-husband who sometimes visits her but also does not reside at her home. Hours of operation will be Monday to Friday between 8:30AM to 6PM. Applicant speaks primarily Mandarin, the language translation service will be used during today's inspection.

The applicant's home is one story home that is neat and clean with heating and ventilation to provide safety and comfort . The home has a 2A10BC fire extinguisher and have functioning carbon monoxide and smoke detectors along a working telephone. LPA reviewed a rental agreement that shows applicant leases the property. Applicant also has LIC 9151 (Landlord Notification) in the facility file. The areas of the day care will consist of living room (main area of day care and isolation area), gated backyard, and hallway bathroom. The "OFF LIMIT" areas are kitchen, garage, front yard, left and right side of the backyard, and all three bedrooms and one master bathroom that will always be locked or closed to prevent access to those areas. Per applicant, she also states that her landlord would sometimes visit the home, however she would only visits and stay in one of the bedroom on the weekends when day care is not operating. LPA informs applicant that all adults would need fingerprint clearance and understand the maximum citation of $500.00 if someone does not have an eligible clearance. Applicant understood. At 10:00am, the backyard play area was observed and is free from defects or dangerous conditions. There are age appropriate new toys for the children to utilize. There are no pools, hot tubs or any other bodies of water on the premises. Per applicant, there are no pets or firearm present at the home. All hazardous materials and toxins are out of the reach of children by installing child safety locks on the cabinets and drawers.

SEE LIC 809 C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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: WEN, QIN
FACILITY NUMBER: 015700356
VISIT DATE: 06/08/2022
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LPA also informs applicant that any playpens and cribs with sleeping children would need to be supervised every 15 minutes and document observations on a sleep log as a requirement of the safe sleep regulation. Applicant understood and states that she has been doing it at her previous day care location. LPA also reviewed that applicant has required immunizations and preventative health and safety training. CPR and First aid training is also current and will expire on 03/01/2023. Mandated reporter training is also completed on 05/27/2022, and needs to be renew every 2 years. LPA also was made aware that the facility has a fireplace, but it is blocked with a child safety gate. All required documents are posted and visible for public review.

There were no deficiencies cited during today's visit.

Exit interview conducted and report was reviewed and appeal rights were also provided with applicant Qin Wen. This home is recommended for licensure as of today, 06/08/2022. This report shall remain on file for 3 years

Applicant 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.

SEE LIC 809 C

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: WEN, QIN
FACILITY NUMBER: 015700356
VISIT DATE: 06/08/2022
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Incidental Medical Services (IMS) policy was discussed. This facility does not provides IMS to children in care at the moment. When any changes to the IMS plan is made, an updated 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.”

LPA discussed the safe sleep regulations with licensee/APPLICANT 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/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.


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.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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