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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313840
Report Date: 01/31/2022
Date Signed: 01/31/2022 12:17:31 PM

Document Has Been Signed on 01/31/2022 12:17 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:MAI, AIZHENFACILITY NUMBER:
304313840
ADMINISTRATOR:MAI, AIZHENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(978) 221-1036
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 10DATE:
01/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Aizhen MaiTIME COMPLETED:
01:00 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA), Alanna Gontarek. LPA met with Licensee, Aizhen Mai, and given a tour of facility. LPA observed licensee and Assistant Nasrin Oshidari caring for (10) children; which included (1) infant, and (9) preschool age children. Licensee was operating within the licensed capacity as specified on license. Hours of operation are from 8:30 a.m. to 6:30 p.m. Monday through Friday. Per Licensee, there are 12 children that are currently enrolled. A current children’s roster was available for review.

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.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. This is a 2-story 4 bedroom, 4 bathroom home. Off limits areas include: garage, hallway closet, one downstairs bathroom, (3) upstairs bedrooms, (2) upstairs bathrooms, and upstairs laundry room. These off-limit areas are made inaccessible by means of child safety gates and latches. Daycare areas include: kitchen, living room/daycare room, one downstairs bathroom, nap room, and back yard.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. There is telephone service via cellphone that is used and the cellphone stays at the facility during operation hours. There is ventilation and heating (central). There are working carbon monoxide detector, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. At 9:50 a.m. LPA observed (2) insect killers in garage. The garage door was observed to not be locked with either a key or combination lock, allowing for children to access the insect killers. LPA advised storage areas for poisons must be locked with a key or combination lock. The restroom that children use was observed to be safe and sanitary.
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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2022
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MAI, AIZHEN
FACILITY NUMBER: 304313840
VISIT DATE: 01/31/2022
NARRATIVE
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Licensee stated there are no firearms or other dangerous weapons in the facility and none were observed during today's inspection. The home has age appropriate toys for the ages served. During today’s inspection where children less than five years old are in care, stairs are barricaded with a safety gate. Appropriate sleeping arrangements via mats were observed. Per licensee, there are no cribs or play pens a the daycare. LPA inspected kitchen. LPA observed knives to be stored in above cabinet, inaccessible to children in care. LPA observed cleaning compounds stored under sink, and inaccessible via latch. LPA observed posted forms: License, Parent Rights poster, and Disaster Plan. LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family child care facility. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be surrounded by a wall. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that can pose a danger to children on the outdoor yard. There are no bodies of water on the premises. There are no pets on the premises.

Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. The licensee Pediatric CPR/First Aid certification expires on 10/17/22, and licensee's assistant's CPR/First Aid certification expires on 12/27/23.



Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles, and Influenza for licensee and assistant were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. The licensee and licensee's assistant are exempt from this requirement due to the training not being available in Farsi (licensee's assistant) or Mandarin (licensee).

All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. At 9:35 a.m. during interview conducted with Licensee, Licensee stated does not keep record of earthquake or disaster drills, and has not conducted a drill since being licensed. During record review, LPA did not observe a drill record in facility files.

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
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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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MAI, AIZHEN
FACILITY NUMBER: 304313840
VISIT DATE: 01/31/2022
NARRATIVE
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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

The licensee understands she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

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.
A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the licensee.
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx

NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
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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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MAI, AIZHEN
FACILITY NUMBER: 304313840
VISIT DATE: 01/31/2022
NARRATIVE
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 Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold

PIN 21-29-CCP Face Covering Requirements and Guidance for Child Care Providers Regarding Coronavirus Disease 2019 (COVID 19) was provided and licensee was to continue to message the “Three W’s”: Wash your hands. Watch your physical distance. Wear a mask. This face covering guidance is for all individuals 2 years and older, except for the exceptions (child’s development, medical exemptions, etc.) that are outlined by CDPH.

Based on LPAs observations, record reviews and interviews, the following violations were observed and are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1, Sections 102417 (g)(A)(1) and 102417 (g)(4)(A) are being cited on the attached LIC 809D.

Exit interview conducted and report was reviewed with the licensee Aizhen Mai. Appeal Rights and deficiencies were discussed. The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

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.

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.

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2022 12:17 PM - It Cannot Be Edited


Created By: Alanna Gontarek On 01/31/2022 at 11:22 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MAI, AIZHEN
FACILITY NUMBER: 304313840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)(A)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, at 9:50 a.m. LPA observed 2 insect killers in garage, and garage door was not locked with either a key or combination lock. The licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2022
Plan of Correction
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Licensee immediately moved poisons (insect killers) to an upper shelf making poisons inaccessible to children in care. Per Licensee, will place poisons in a plastic container, locking with 4 combination locks, and email a picture of the corection to LPA by the due date of 2/4/22.
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:Patricia Magana
LICENSING EVALUATOR NAME:Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2022 12:17 PM - It Cannot Be Edited


Created By: Alanna Gontarek On 01/31/2022 at 11:22 AM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: MAI, AIZHEN
FACILITY NUMBER: 304313840

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2022

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 interview and record review, at 9:35 a.m. during interview conducted with Licensee, Licensee stated does not keep record of earthquake or disaster drills, and has not conducted a drill since being licensed. During record review, LPA did not observe a drill record in facility files. The licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2022
Plan of Correction
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Per Licensee, will conduct a fire and earthquake drill by the due date of 2/4/22. Per Licensee, will document drill on drill log, and email drill to LPA Gontarek.

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:Patricia Magana
LICENSING EVALUATOR NAME:Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2022


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