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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 364845981
Report Date: 09/25/2024
Date Signed: 09/25/2024 05:07:39 PM

Document Has Been Signed on 09/25/2024 05:07 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SHEN FAMILY CHILD CAREFACILITY NUMBER:
364845981
ADMINISTRATOR/
DIRECTOR:		YUZHEN WANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 860-5818
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
09/25/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Wei Shen LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On the date and time listed above Licensing Program Analyst (LPA) Giselle Carbullido arrived at the facility to conduct an annual inspection. LPA was granted entry by Licensee, Yuzhen Wang and Assistant, Fang Shen. Assistant provided initial translation from LPA to Licensee, Yuzhen Wang for first part of visit, then departed. Licensee, Wei Shen was not present but available and reviewed deficiencies and received verbal review of report during the course of 4 phone calls. Licensee, Yuzhen Wang signed for receipt of report. LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following: Normal days and hours of operation are Monday -Friday 8:00AM -6:00PM
OFF-LIMIT AREAS INCLUDE: All of upstairs, Garage and Kitchen: See LIC809D for deficiency cited.
At 11:30AM LPA observed 3 infants and one toddler in the kitchen area marked off limits.
• The inspection consisted of reviews of the following domain: Physical Plant, Care and Supervision, Records, Facility Administration, Staffing Ratio and Capacity, Personal Rights The inspection found the facility to be in compliance in these domains, except as noted on the LIC809D. Deficiencies were cited this visit; and technical advisories were given.
• The facility is operating within the licensed capacity and appropriate ratios
• Appropriate supervision provided during visit
• A working telephone is present. No fire place.
• Appropriate fire extinguisher present; carbon and smoke detectors operational and tested by Licensee.
• The facility is clean and orderly and has adequate heating and ventilation for safety and comfort.
• Stairs are not gated, LPA observed gate to entry of main daycare room and staff's children access stairs with staff. See LIC809D for deficiency cited.
• All hazardous items inaccessible to children and toxins are locked. See LIC809D for deficiency cited
• Per Licensee, no guns or weapons present. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
• Outdoor play area is fenced, or appropriate supervision is present.
• Clean, safe and age-appropriate toys for indoor and outdoor activity
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SHEN FAMILY CHILD CARE
FACILITY NUMBER: 364845981
VISIT DATE: 09/25/2024
NARRATIVE
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No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
• Pediatric CPR and First Aid Card expire 03/2026
• Health & Safety Certificate - completed on 1/27/2020 see LIC9102TV technical advisory • Mandated reporter: Child Care Expires: 05/2026 Fire clearance: 01/28/2021
Current roster on file yes Documentation of fire drills on file - Last drill: 10/26/2023 See LIC809D for deficiency cited Verification of control of property - yes Children’s records are not complete See LIC809D for deficiency cited Employee’s records are not complete See LIC809D for deficiency cited
Facility sketch, Emergency Disaster Plan & Notification of parent Rights are posted. Licensee was informed: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
The Licensee was informed of their reporting requirements and provided the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov

• To receive important licensed -related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

• 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
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SHEN FAMILY CHILD CARE
FACILITY NUMBER: 364845981
VISIT DATE: 09/25/2024
NARRATIVE
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•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.
• 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/inspection-process.
• A notice of site visit was given and must remain posted for 30 days.
• Exit interview conducted and report was reviewed with the licensees Wei Shen, Yuzhen Wang
SUPERVISORS NAME: Gilbert Sena
LICENSING EVALUATOR NAME: Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 09/25/2024 05:07 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 09/25/2024 at 03:19 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SHEN FAMILY CHILD CARE
FACILITY NUMBER: 364845981

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
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: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) the licensee did not comply with the section cited above in that stairs do not have gate at bottom of stairwell but at entry to main daycare room. LPA observed S1 and their 2 children (under 5) accsss stairwell and children passing stairs with staff for pick up and drop off which poses/posed a potential health, safety or personal rights risk to persons in care. Per staff interviews, did not know regualtion applied to their own children.
POC Due Date: 09/27/2024
Plan of Correction
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Facility will provide addtional gate at bottom of stairwell by POC due date. LPA reviewed regulation with Assistant and Licensee that regulation applies to all children under 5 during hours of operation.
Type B
Section Cited
CCR
102417(g)(4)
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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in that at 11:45AM LPA observed cleaners and bathroom products accessible to children within the bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/27/2024
Plan of Correction
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Facility will submit proof of making cleaners and bathroom products inaccessible to childern in care by POC due date to the department.
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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 09/25/2024 05:07 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 09/25/2024 at 03:19 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SHEN FAMILY CHILD CARE
FACILITY NUMBER: 364845981

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(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: (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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in that last drill record available for review was 10/26/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Facility will complete fire drill by POC due date and send proof (video) to the department.
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and (record review)], the licensee did not comply with the section cited above in that facilty is not using safe sleep logs for 15 minute checks which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Facility will complete 15 minute safe sleep logs for all infants enrolled by POC due date and submit proof of logs to the department. 15 minute safe sleep log provided to Licensee
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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 09/25/2024 05:07 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 09/25/2024 at 03:19 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SHEN FAMILY CHILD CARE
FACILITY NUMBER: 364845981

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on (record review)], the licensee did not comply with the section cited above in that S1 did not have mandated reporter available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Facility will submit mandated reporter certificate for S1 to the department by POC due date or earlier.
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and record reveiw , the licensee did not comply with the section cited above in that at 11:48AM LPA observed 3 infants and one preschool in highchairs in the kitchen area that is marked off limits which poses/posed a potential health, safety or personal rights risk to persons in care. Facility sketch also shows kitchen area as off limits.
POC Due Date: 09/25/2024
Plan of Correction
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Children removed from off limit area to main day care room. Cleared during this visit.
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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 09/25/2024 05:07 PM - It Cannot Be Edited


Created By: Giselle Carbullido On 09/25/2024 at 03:19 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SHEN FAMILY CHILD CARE
FACILITY NUMBER: 364845981

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) and (record review)], the licensee did not comply with the section cited above in that 4 out of 5 files reviewed had missing immunizations (C2-C5) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Facility will submit proof immunizaions for C2-C5 by POC due date or earlier to the department.
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:Gilbert Sena
LICENSING EVALUATOR NAME:Giselle Carbullido
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
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