304314150-4-25-2023-06-CC-STOE-CR8U8Y-20230425152217

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304314150
Report Date: 04/25/2023
Date Signed: 04/25/2023 03:22:34 PM

Document Has Been Signed on 04/25/2023 03:22 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:	CHIBA, SAYORI		FACILITY NUMBER:	304314150
ADMINISTRATOR:	CHIBA, SAYORI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 733-0521
CITY:	IRVINE	STATE: CA	ZIP CODE:	92606
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	04/25/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Sayori Chiba, Applicant		TIME COMPLETED:	03:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Stacy Torrence conducted an announced in-person Pre-Licensing inspection for a new Large Child Care home. LPA met with applicant Sayori Chiba who provided a tour of the new home. A review of the Facility Personnel Report Summary indicates two adult residents, who require caregiver background check clearances exemptions is received and is cleared. Per applicant, there are no minor children living in the home. Applicant stated, she is not currently registered with any Resource Foster Care agency or holds a Resource foster parent license. Applicant was reminded if changes to notify the licensing office. The applicant is requesting a Large Family Childcare Home license. Per applicant, operation hours will be Monday through Saturday; 8:00 AM-10:00 PM and care and supervision shall be provided to children ages newborn to 9 years old (Infant, Preschool, and School-Age). All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a single-story home with three bedrooms, two bathrooms, living room, den, kitchen, dining room, front yard (fenced), backyard(fenced), and garage. There is a fireplace in the home, located in the living room; barricaded by a piano. There are no stairs in the home. Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant state (that there are no poisons on the premises). Applicant was advised that any poisons must be locked with a key or combination lock. Applicant stated there are no weapons or firearms on the premises. LPA informed applicant, when firearms are present, they must be locked and stored separately from the ammunition.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHIBA, SAYORI	FACILITY NUMBER: 304314150
	VISIT DATE: 04/25/2023

NARRATIVE

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Based on the Facility Sketch submitted, areas off limits to children and parents are: Applicant has designated three bedrooms, one bedroom, kitchen, and garage, as the off-limit area. Applicant has placed child proof safety gate at the entrance of the kitchen; ensuring dangerous items are inaccessible to the children in care. Applicant has placed a child proof cover over the bedroom doorknobs, ensuring this area is inaccessible to children in care. Applicant’s garage door has a lock on it, making sure the area is inaccessible to the children.

Applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

Areas Designated for Day care activities: Applicant has designated the living room, bathroom, den, dining room, front yard, and backyard, as the day care areas.

Upon arrival applicant will receive the children at the front door, to gain access to the home.

The designated Child Care areas were observed to have age-appropriate toys and educational items.

Children will nap, in the living room, and mats shall be used. Infants will sleep in the dining room and cribs shall be used. Applicant stated parents will provide wipes, lotions, diapers, and formula. Applicant stated infants will be changed on mat, located on the floor. LPA advised applicant, when changing infants to always supervise the infants visually. Applicant stated parent will provide the linen and blankets.

Applicant stated she and the parents will provide food for the children. Applicant was informed if children bring food from home to ensure the children’s name is on their lunch bag and refrigerated properly.

Per applicant, upon arrival children’s temperature will be taken, hands shall be sanitized, and the children shall be guided into the designated day care areas.

COVID-19 guidelines and precautions were discussed with the applicant.

The children’s bathroom is located in the hallway and was observed to be safe and free of hazardous items. Applicant has two small step tools for children in the bathroom.

Per applicant, there are no animals in the home.

THERE IS OUTDOOR PLAY AREA: Outdoor play activities will be conducted in the backyard and front yard, which is appropriately fenced. LPA observed play equipment to be safe and hazardous free. There are no bodies of water on the premises.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHIBA, SAYORI	FACILITY NUMBER: 304314150
	VISIT DATE: 04/25/2023

NARRATIVE

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The value on the 2A10BC fire extinguisher indicates fully charged, as indicated on service tag observed. Smoke and carbon monoxide detectors were tested and are operable.

Applicant have not completed the required Health and Safety with Nutrition and Lead Poisoning component Training.
Applicant has completed the approved EMSA Pediatric CPR and Pediatric First Aid and expires on 07/24. There are first aid supplies available.
In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR certification and a valid criminal record clearance associated to the facility license / TB clearance and Immunization.

Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.

The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.
Applicant was also made aware of the Child Advocacy program so she could receive the updated Quarterly reports and other information in a timely manner. ChildCareAdvocatesProgram@dss.ca.gov

Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
Fire and safety drills must be performed every six months and documented for review by the Department.
Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
No smoking, No Johnny jumpers, No saucer chairs, and any other item that falls into that category are not permitted in the facility.
All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
Licensees shall reveal each facility license number in all advertisements, publications or announcements with the intent to attract clients.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHIBA, SAYORI	FACILITY NUMBER: 304314150
	VISIT DATE: 04/25/2023

NARRATIVE

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UPDATE: H&S 1597.622: Commencing September 1, 2016, 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.
The applicant has submitted proof of immunizations.

UPDATE: Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com. Applicant has completed the required mandated reporter training.

Incidental Medical Services (IMS): LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.

Applicant plans to store the medication, in the den, on the top shelf.

LPA advised the applicants how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:

CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHIBA, SAYORI	FACILITY NUMBER: 304314150
	VISIT DATE: 04/25/2023

NARRATIVE

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INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by Law to post the following:
Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handout for a Small Family Child Care Home and Large Family Child Care Home was provided.

The following was discussed with the applicant:
Applicant 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 applicant 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 applicant 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.

Per applicant, there are no dual licenses at this address. Applicants’ email address was obtained during this inspection. The applicant was advised that email may be public information.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CHIBA, SAYORI	FACILITY NUMBER: 304314150
	VISIT DATE: 04/25/2023

NARRATIVE

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Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

The facility was in compliance for a Large Family Child Care Home with Title 22 Regulations, in regard to physical plant; however, the applicant is pending the Health and Safety with Nutrition and Lead Poisoning Training. Therefore, a provisional license for 90 days will be issued, which will expire on 07/25/2023.

Appeal rights were presented and Exit interview was conducted with the applicant Ms. Sayori Chiba.

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.

SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Stacy Torrence
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC809 (FAS) - (06/04)

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