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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423582
Report Date: 02/08/2022
Date Signed: 02/08/2022 03:00:33 PM

Document Has Been Signed on 02/08/2022 03:00 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:CHEN, SHIRLEYFACILITY NUMBER:
013423582
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
02/08/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:08 PM
MET WITH:Shirley ChenTIME COMPLETED:
03:15 PM
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On Tuesday, February 8, 22, Licensing Program Analyst (LPA) Caroline Colson met with Shirley Chen and her assistant Xue Bing Tan for an unannounced increase in capacity prelicensing and technical assistance inspection at 1:08 PM. There are two infants and 4 preschool children present. The home was toured to conduct a health and safety inspection. Ms. Chen was informed of the new civil penalty assessments of up to $500 per adult during the initial inspection for not having cleared fingerprints on file (if needed) before contact with the day care children.

The home is a duplex. The home consist of two bedrooms, living room with dinning area, kitchen, a door that leads to the fenced back side yard, bathroom, pantry closet and fenced shared front yard. Shirley will use her shared fenced front yard on a schedule because her neighbor is a licensed provider who uses the yard as well. The second bedroom, pantry closet, kitchen, and the door leading to fenced back side yard are the Off Limits Areas. There is 3A40BC fire extinguisher, working smoke alarm and working carbon monoxide detector. She has heating for the home. Ms. Chen states that there are no firearms in the home. There are toys available for the children. Her CPR and First Aid certificates are current and expire on August 21, 2023. The isolation area will be the second bedroom. There are no pets at this time.



Please See LIC 809 C for additional information
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CHEN, SHIRLEY
FACILITY NUMBER: 013423582
VISIT DATE: 02/08/2022
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REMINDERS/RESOURCES
· Criminal Background Clearance: All assistants, volunteers, frequent adult visitors (adults are individuals 18 years of age or older) must be fingerprint cleared and associated to the facility prior to be in the presence of children in care. Failure to comply, requires an immediate civil penalty of $100 to $3000 per person, per incident.

· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

· NEW LAW: Safe Sleep Regulations: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep

· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse.

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

· Licensees may register to receive child care updates: www.myccl.ca.gov

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

Licensee will submit children's immunization records, add her license number to all advertisements, cover both plant boxes located outside in fenced play yard and provide schedule of outdoor play time before obtaining a license for a large family day care home.

There were no deficiencies cited during the inspections.
An exit interview was conducted. This report must be available for public review for 3 years.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Caroline Colson
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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