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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700356
Report Date: 05/30/2023
Date Signed: 05/30/2023 04:39:59 PM

Document Has Been Signed on 05/30/2023 04:39 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:WEN, QINFACILITY NUMBER:
015700356
ADMINISTRATOR:WEN, QINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 996-8650
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 3CENSUS: 3DATE:
05/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:03 PM
MET WITH:Qin WenTIME COMPLETED:
04:40 PM
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On 5/30/2023 at 3:03pm Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Qin Wen for a Required – 1 Year Inspection. Present during the inspection was the Licensee and three (3) infants. Licensee lives in the home with the owner of the home, Hua Yang. Licensee’s home was toured for a health and safety inspection. The facility operates from 8:30am – 6:00pm, Monday - Friday.

ON LIMITS AREA: Kitchen, Living Room, Hallway Bathroom and Front Portion of the Backyard
OFF LIMITS AREA: Bedroom's #1, #2 and #3, Bathroom attached to Bedroom #1, Backyard beyond the gated play area and Garage
ISOLATION AREA: Living Room

The facility is a single-story home rented by the Licensee. The inside of the home was observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. All off-limit areas are made inaccessible with gates and locks. Currently some children bring their food from home, and licensee provides food for the other children. All food that is brought from the children’s home is properly labeled and stored. Licensee stated that they do not transport children. There are no pets and no firearms in the home.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/30/2023
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: WEN, QIN
FACILITY NUMBER: 015700356
VISIT DATE: 05/30/2023
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The home has one (1) fully charged 2A10BC fire extinguisher on the wall next to the fireplace. There is one (1) working combination smoke/carbon monoxide detector and a stand-alone smoke detector in the living room. The home is equipped with central heat and window air conditioning units for proper ventilation. There are three (3) play yards (pack-n-plays) and one (1) crib used for sleeping that are clean and well maintained. LPA observed all bedding is clean and in good condition. The fireplace in the living room is gated and blocked by furniture making it inaccessible to the children in care. The backyard is fully fenced and well maintained with ample age-appropriate materials for the children. The area used for childcare is fenced as well making the off-limit area of the backyard inaccessible. LPA did not observe any bodies of water in or around the home that could be a potential danger to the children in care.

Licensee’s Health and Safety training with lead poisoning component has been completed. Licensee’s Pediatric CPR and First Aid training's are complete and expires 4/15/2025. Licensee’s Mandated Reporter training certificate is complete and expires 10/16/2024. Fire/disaster drills have been conducted with the last drill logged 1/10/2023. All adults living and working in the home have obtained a criminal record clearance. All required forms are posted and visible for public view in the entry way of the home. LPA obtained the children's files, facility files and facility roster. All files were complete.

No deficiencies were cited during this inspection.

Licensee was reminded that California Law requires Licensee 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 email. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drills must be conducted every six (6) months and documented. Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
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: 05/30/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

LPA discussed the safe sleep regulations with Licensee 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 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
Exit interview conducted and report was reviewed with Licensee Qin Wen.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2023
LIC809 (FAS) - (06/04)
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