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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016532
Report Date: 06/16/2022
Date Signed: 06/16/2022 04:29:25 PM

Document Has Been Signed on 06/16/2022 04:29 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:LI FAMILY CHILD CAREFACILITY NUMBER:
198016532
ADMINISTRATOR:LI, ANGELAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 307-1857
CITY:MONTEREY PARKSTATE: CAZIP CODE:
91755
CAPACITY: 14TOTAL ENROLLED CHILDREN: 44CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Licensee, Angela LiTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Mireya García conducted an unannounced annual required inspection. Due to COVID- 19 precautionary measures were taken, licensing staff present during inspection wore appropriate personal protective equipment. LPA met with licensee, Angela Li who guided analyst on a tour of the facility. There were four (4) children present during this inspection two (2) being infants. Licensee states that there are currently four (4) children enrolled. Facility operation hours are Monday through Friday from 8:00 AM to 6:00 PM.

Family members residing in the home are four (4) adults and Licensee’s one (1) minor child.

This is a two-story home which consists of 3 bedrooms, 3 restrooms, kitchen, dining room, living room, and attached garage, side yard (fenced). The children use the restroom (located downstairs), dining room, living room, side yard. Per licensee, areas off limits to children and parents include: The entire second floor which consist of; 3 bedrooms, 2 restrooms, kitchen, attached garage (which are all made inaccessible by child proof safety gates. The LPA toured all areas used by children during this visit. Report continues on next page 1 of 6.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LI FAMILY CHILD CARE
FACILITY NUMBER: 198016532
VISIT DATE: 06/16/2022
NARRATIVE
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During this tour, the following was noted: At 1:55 p.m., LPAs toured through the interior of the home. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and central heating for safety and comfort. There were safe toys, play equipment and materials observed for children. There is a working telephone service maintained in the home. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. The licensee states that there are no poisons in the home. The licensee does understand that poison must be locked with a key or combination lock.

During a walk-through of the second floor, at 2:15 p.m.,LPA Garcia observed that adult resident Johnson Lin (Licensee’s adult son) present and is not fingerprint cleared and associated to the facility. LPA determined through Licensee disclosure and verification of the Licensing Information System (LIS) that resident is not fingerprint cleared. Licensee stated that son turned 18 years old on 01/12/22. This poses an immediate risk to the health and safety of children in care. A civil penalty of $500 was assessed on this day.

LPA observed and inspected sleeping equipment for infants. LPA observed one play yard for 1 infant who is unable to climb out of the play yard. LPA observed one infant awake and one 14 month old infant napping on a mat. All equipment meets the US Consumer Product Safety Commission safety standards. LPA observed that play yard is free from loose articles and objects.


Report continues on next page 2 of 6.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LI FAMILY CHILD CARE
FACILITY NUMBER: 198016532
VISIT DATE: 06/16/2022
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There is no objects hanging above or attached to the side of the play yard. LPA observed that play yard do not hinder the entrance or exit to and from the space they are sleeping in. Each infant has their individual bedding and is washed weekly as required. Soiled bedding is replaced when wet or soiled and is placed in an area inaccessible to infants. Pacifiers were not observed. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months should be placed on their back for sleeping.

LIC 9227 (Individual Sleeping Plan) for infants up to 12 months was review. Title 22 Regulation Section 102425(j) Infant Safe Sleep was discussed with the Licensee, including but not limited to documentation that shall be maintained. PIN 20-24-CCP Recently approved safe sleep regulations in effect was discuss and a copy in English/Chinese was provided.

Per licensee, there are no weapons, firearms or bodies of water on the premises. Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The valve on the required 2A 10BC fire extinguisher indicates fully charged with a service tag dated 04/05/2022. Smoke detector and carbon monoxide detector located in the kitchen was tested at 2:49 p.m. and are in operable condition. The licensee’s Pediatric First Aid and CPR expires on 03/24.


Report continues on next page 3 of 6.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LI FAMILY CHILD CARE
FACILITY NUMBER: 198016532
VISIT DATE: 06/16/2022
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. Per Licensee there are currently no children enrolled who required IMS. 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

SB792 (Immunization Requirements for Staff and Employees) was discussed with the Licensee.

AB1207 Mandated Child Abuse Reporting – On or before March 30, 2018 any person who works in a child care facility shall complete the training and renew the training every 2 years. Website provided: https://www.mandatedreporterca.com/training/child-care-providers


Report continues on next page 4 of 6.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LI FAMILY CHILD CARE
FACILITY NUMBER: 198016532
VISIT DATE: 06/16/2022
NARRATIVE
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The following was discussed:
· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.
· The Licensee shall be present in the home and shall ensure that children are supervised at all times.
· Children shall not be left in park vehicles.
· The capacity specified on the license shall be the maximum number of children for whom care can be provided.
· Car seats shall only be used for transportation purposes and shall not be used for sleeping.
· All children in care have the right to receive safe, healthful, and comfortable accommodations, furnishings and equipment.
· When a child shows signs off illness, they will be separated from other children until the nature if the illness is determined.
LPA reviewed and issued the LIC 311 - Forms/Records to Keep in Your Family Child Care Home.
CHILDREN’S FORMS/RECORDS, FACILITY FORMS/RECORDS and INFORMATION TO BE POSTED, Disaster drills, posting requirements, children records requirements, mandated child abuse and injury/death reporting, and criminal record transfer requirements were discussed.
Report continues on next page 5 of 6.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: LI FAMILY CHILD CARE
FACILITY NUMBER: 198016532
VISIT DATE: 06/16/2022
NARRATIVE
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LPA advised the licensee how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). Acknowledgement of Receipt (LIC 9224 form) must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the Acknowledgement of Receipt of Licensing Reports (LIC 9224 English/Chinese) Forms during this visit.

The following deficiencies are being cited in accordance to Title 22 of the California Code of Regulations and Health & Safety codes. Please refer to LIC809D for documentation of deficiencies cited.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with facility representative, Angela Li.

Report ends here page 6 of 6.
SUPERVISORS NAME: Brandi VanOosten
LICENSING EVALUATOR NAME: Mireya Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2022 04:29 PM - It Cannot Be Edited


Created By: Mireya Garcia On 06/16/2022 at 03:57 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: LI FAMILY CHILD CARE
FACILITY NUMBER: 198016532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and Licensee Angela disclosure that resident adult son Johnson Lin is not fingerprint cleared and associated to the facility. LPA determined through the Licensing Information System (LIS) that resident is not fingerprint cleared. This poses an immediate health and safety risk to children in care.
POC Due Date: 06/16/2022
Plan of Correction
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During LPAs visit LPA provided Licensee with LIC9163 and resource location where son can get fingerprinted. Per Licensee, adult son will go get fingerprints today and will submit to LPA Garcia proof of receipt of payment for fingerprint processing via email.
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:Brandi VanOosten
LICENSING EVALUATOR NAME:Mireya Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2022 04:29 PM - It Cannot Be Edited


Created By: Mireya Garcia On 06/16/2022 at 03:57 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: LI FAMILY CHILD CARE
FACILITY NUMBER: 198016532

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review of infant children #3 & #4 and Licensee's disclosure no documentation on file for sleeping logs of infants every 15 minutes.
POC Due Date: 06/30/2022
Plan of Correction
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Per Licensee, she will begin to document the physical check of infants in care while they are sleeping every 15 minutes and will send sleeping logs to LPA Garcia via email by POC due date 06/30/22. LPA Garcia provided
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Brandi VanOosten
LICENSING EVALUATOR NAME:Mireya Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


LIC809 (FAS) - (06/04)
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