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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434408002
Report Date: 08/28/2023
Date Signed: 08/28/2023 05:15:40 PM

Document Has Been Signed on 08/28/2023 05:15 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:JIA-RAY LEARNING CENTER, INC.FACILITY NUMBER:
434408002
ADMINISTRATOR:RENEE OLSONFACILITY TYPE:
850
ADDRESS:2798 SOUTH BASCOM AVENUETELEPHONE:
(408) 480-4532
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY: 35TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
08/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Amie Oman and Chia Yi LiTIME COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Samantha Yip and Ashley Lopez conducted an unannounced Case Management- Other inspection. LPA met with Director Amie Oman and explained the reason of the inspection. Licensee Chia Li arrived around 4:50PM.

LPAs observed that the blue plastic drum has a hole on the top. The hole is sharp. LPA also observed that the yellow plastic wall on the playstructure has a hole on the top left and right side; along with the bottom of the wall and does give in when pushed on. LPAs also observed that the flooring on the playstructure is starting to lift in areas, which poses as a tripping hazard. Staff informed LPAs that the playground area is currently off-limits.

As a result of this inspection, a Type B citation was issued. Exit interview was conducted and report was reviewed with Licensee Chia Yi Li. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2023
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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Document Has Been Signed on 08/28/2023 05:15 PM - It Cannot Be Edited


Created By: Samantha Yip On 08/28/2023 at 03:58 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JIA-RAY LEARNING CENTER, INC.
FACILITY NUMBER: 434408002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2023
Section Cited
CCR
101239(m)(1)

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Fixtures, Furniture, Equipment and Supplies. All play equipment and materials used by children shall be age-appropriate. The licensee shall provide a variety of age-appropriate equipment, toys and materials in good condition...
This requirement is not met as evidenced by:
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By 09/05/2023, the center will submit work order or plan for the playstructure and proof once it has been fixed to Licensing.
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Based on observation, LPA observed that there are holes in the playstructure and flooring on the playstructure is starting to lift, which could cause a tripping hazard to children. This poses a potential health and safety risk to chidlren in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023


LIC809 (FAS) - (06/04)
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