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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409385
Report Date: 05/16/2024
Date Signed: 05/16/2024 04:03:17 PM

Document Has Been Signed on 05/16/2024 04:03 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:JOHNSON, YUKAFACILITY NUMBER:
073409385
ADMINISTRATOR/
DIRECTOR:		JOHNSON, YUKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 457-7223
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/16/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:YUKA JOHNSONTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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On 5/16/2024 at 12:45PM Licensing Program Analyst (LPA) Tasha Alexander met with Licensee Yuka Johnson for an Annual/Random Inspection. Present during the inspection was the Licensee and her four year old daughter. Licensee lives in the home with her two minor children, a 4 year old daughter and 9 year old son. Licensee’s home was toured for a health and safety inspection. The facility operates from 9:00am – 1:00pm, Tuesday - Thursday. Per licensee she also hosts days care on Fridays from 9am-12pm at a nearby farm.

ON LIMITS AREA: The first level-family room/day care room & 1.5 bathroom
OFF LIMITS AREA: 2nd level of the home-kitchen and living room, 3rd level of the home-4 bedrooms, 2 bathrooms.
ISOLATION AREA: an area in the day care room

The facility is a single-story home owned 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. Licensee stated that she provides all food for the children. All food that may be brought from the children’s home will be properly labeled and stored. 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 detector/carbon monoxide combo in the living room. The fireplace in the day care room is covered making it inaccessible to the children in care. Licensees uses child sized picnic tables out doors for eating. Per licensee, the fcch is ran as half day programs and children do not nap at her facility. The home is equipped with central heat and air. Continued on 809-C
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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: JOHNSON, YUKA
FACILITY NUMBER: 073409385
VISIT DATE: 05/16/2024
NARRATIVE
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The backyard is fully fenced, clean and has ample age appropriate materials for the children in care. There is a plastic play structure that has been anchored into the ground for extra safety. The slide on the structure is properly cushioned as well. There are storage areas in the back yard that are gated off making them inaccessible to the children. There are fruit trees in the yard as well. 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 complete and expires 1/2025. Licensee’s Mandated Reporter training is complete and expires 10/3/25. LPA obtained the fire/disaster drill log and it is not up to date today. All adults living and working in the home have obtained a criminal record clearance. All required forms are posted outside of the childcare room in the backyard on the wall near the sliding glass window for parents to see. LPA obtained the children’s files, helper's file 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
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
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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: JOHNSON, YUKA
FACILITY NUMBER: 073409385
VISIT DATE: 05/16/2024
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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. Licensee is not caring for infants at this time.

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 Yuka Johnson .
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2024 04:03 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 05/16/2024 at 03:46 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: JOHNSON, YUKA
FACILITY NUMBER: 073409385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

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 is not met as evidenced by a review of records which revealed the licensee has not conducted the required fire/disaster drill
POC Due Date: 05/30/2024
Plan of Correction
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Licensee will conduct a fire/disaster drill with children in care and submit a copy of the updated log to community care licensing by 5/30/24

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: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/16/2024 04:03 PM - It Cannot Be Edited


Created By: Tasha Hackett-Alexander On 05/16/2024 at 03:46 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: JOHNSON, YUKA
FACILITY NUMBER: 073409385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day 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 licensee is unable to locate her immunization records today.
POC Due Date: 05/30/2024
Plan of Correction
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Licensee will locate her immunization records and submit a copie to community care licensing by 5/50/24
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: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


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