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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409152
Report Date: 05/22/2024
Date Signed: 05/22/2024 04:39:03 PM

Document Has Been Signed on 05/22/2024 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:SUNG, SYLVIAFACILITY NUMBER:
073409152
ADMINISTRATOR/
DIRECTOR:		SUNG, SYLVIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 264-2504
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
05/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:SILVIA SUNGTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
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On 5/22/2024 at 1:30pm Licensing Program Analyst (LPA) Tasha Alexander met with Licensee Silvia Sung for an Annual/Random Inspection. Present during the inspection was the Licensee, her husband, 3 minor children, and five (4) preschool age child and one (1) infant. Licensee lives in the home with her husband, Gatot Tirta and 3 minor daughters ages 13 year old, 9 years old and 6 years old. Licensee’s home was toured for a health and safety inspection. The facility operates from 8:00am – 5:30pm, Monday - Friday.

ON LIMITS AREA: Dining area, downstairs bedroom, living room, downstairs bathroom, backyard
OFF LIMITS AREA: The entire upstairs, which includes 3 bedrooms, 2 bathrooms and the laundry room, the kitchen, and the garage.
ISOLATION AREA: The couch in the Living Room

The facility is a two-story home owned by the Licensee and her husband. 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. Licensee stated that she provides all food for the children. Licensee stated that she does not transport children. There are no pets and no firearms in the home.

There is one (1) fully charged 2A10BC fire extinguisher in the childcare room. There is one (1) working smoke/carbon monoxide detector combo in the hall next to the downstairs bedroom/nap room. The no fireplace in the home. Licensee uses highchairs and age appropriate tables/chairs for eating. There is 1 play yard used for sleeping. All napping equipment is clean, well maintained and in proper working order. The home is equipped with central heat and air for proper ventilation. Continued on 809-C
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SUNG, SYLVIA
FACILITY NUMBER: 073409152
VISIT DATE: 05/22/2024
NARRATIVE
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The backyard is fully fenced, clean and has ample age appropriate materials for the children in care. LPA did not observe any harmful bodies of water in or around the home.

Licensee is operating within their licensed capacity and is in ratio. Licensee’s Health and Safety training with Lead Poisoning component has been completed and Pediatric CPR and First Aid training is also complete. Both were completed in April 2024, but the company has not provided licensee with the updated cards as of yet (email shown). Mandated Reporter training expired 6/11/23. LPA obtained the fire/disaster drill log, log is and it is not up to date with the last log 3/3/22. All adults living and working in the home have obtained a criminal record clearance. All required forms are posted in the childcare room by the entrance door. LPA obtained the children’s files, and facility roster. All files were complete.

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 drill must be conducted every six (6) months and documented. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.
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

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.

Continue on 809-C
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
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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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: SUNG, SYLVIA
FACILITY NUMBER: 073409152
VISIT DATE: 05/22/2024
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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.

Please see 809-d for citation
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Licensee Silvia Sung.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
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Document Has Been Signed on 05/22/2024 04:39 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 05/22/2024 at 04:12 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SUNG, SYLVIA
FACILITY NUMBER: 073409152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY A REVIEW OF RECORDS WHICH REVEALED THE FIRE/DISASTER DRILL LOG IS NOT UP TO DATE
POC Due Date: 06/05/2024
Plan of Correction
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Licensee will conduct a fire/disaster drill with children in care, document and submit a copy of the updated log to community care licensing by 6/5/24

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:Mayla Mendoza
LICENSING EVALUATOR NAME:Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


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Document Has Been Signed on 05/22/2024 04:39 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 05/22/2024 at 04:12 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SUNG, SYLVIA
FACILITY NUMBER: 073409152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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A REVIEW OF RECORDS Based on(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Today the mandated reporter certificate is expired
POC Due Date: 06/05/2024
Plan of Correction
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Licensee will update her mandated reporter training and submit a copy of the updated certificate to community care licensing by 6/5/24
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. A REVIEW OF RECORDS which revealed two children in care do not have immunization records in file
POC Due Date: 06/05/2024
Plan of Correction
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Licensee will obtain immunization records from the children's parents/guardian and submit copies to community care licensing by 6/5/24
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:Mayla Mendoza
LICENSING EVALUATOR NAME:Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2024 04:39 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 05/22/2024 at 04:12 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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: SUNG, SYLVIA
FACILITY NUMBER: 073409152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. A REVIEW OF RECORDS, which revealed two children do not have the signed parent's rights receipt in file
POC Due Date: 06/05/2024
Plan of Correction
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Licensee will have each parent sign the parent's rights form to be put into their child's file. Licensee will submit copies of the receipts to community care licensing by 6/5/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mayla Mendoza
LICENSING EVALUATOR NAME:Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


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