434409289-1-14-2025-07-CC-SYUU-DCWNM5-20250114093430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409289
Report Date: 01/09/2025
Date Signed: 01/14/2025 09:36:32 AM

Document Has Been Signed on 01/14/2025 09:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	CHAO, THERESA		FACILITY NUMBER:	434409289
ADMINISTRATOR/ DIRECTOR:	CHAO, THERESA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 406-4261
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 5	CENSUS: 5	DATE:	01/09/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:38 AM
MET WITH:	Theresa Chao		TIME VISIT/ INSPECTION COMPLETED:	02:10 PM

NARRATIVE

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Licensing Program Analyst (LPA), Shine Yu, conducted an unannounced Annual Inspection 10:38 am. Licensee brought children out taking a walk with her assistant. They retuned home 10 minutes after LPA called licensee.

LPA observed the following materials posted on the bulletin board, including the Facility License, Notification of Parents' Rights (PUB 393) and Fire Drill check log. The last fire drill conducted was 6/21/2024. Facility's operating hours are Monday to Friday 8:30AM to 6PM. All the children enrolled now are full time. LPA acquired a copy of current Children's roster. Present are 1 employee and 5 children, including 3 under 2 years old. LPA observed 15 minutes check list.

LPA reviewed a random selection of children's file and observed that notification of parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification forms are in each file. LPA also reviewed the staff files for the following records: LIC 9052 Employee Rights, the Immunization Record showing immunity to measles (MMR), pertussis (Tdap). Licensee's pediatric First Aid & CPR expires at Aug, 2025. Employee Hsin's pediatric 1st Aid & CPR expires 8/19/2025.

LPA toured the facility with licensee. Licensee keep the bathroom is clean. There is smoke detector and carbon monoxide detector in day care room and children sleeping room. LPA observed a crib with toy inside while there is no child. Licensee removed toy and cover sheet right away. There are age appropriate toys for children. Licensee stated there is no firearm in the facility. The fireplace is barricaded properly and in the activity room. There is no body of water observed outside of play yard. The outdoor play area is enclosed with appropriate fence and safe for children.

Continue on next page, LIC 809C

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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 01/14/2025 09:36 AM - It Cannot Be Edited

Created By: Syhshyan Yu On 01/09/2025 at 12:58 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: CHAO, THERESA	FACILITY NUMBER: 434409289
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 2 out of 2 fire extinguishers, both are out of date and needle is not in green range which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2025
	Plan of Correction
1 2 3 4	Licensee will purchased a new fire extinguiser with receipt. Licsensee will submit a plan of correction to LPA within a week and constantly inspect the fire extinguisher to prevent this issue happened again in the future.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Gladys Kuizon

LICENSING EVALUATOR NAME:

Syhshyan Yu

LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CHAO, THERESA	FACILITY NUMBER: 434409289
	VISIT DATE: 01/09/2025

NARRATIVE

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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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-andresources/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.

Licensee stated there is no medication provided in the facility. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

Continue on next page, LIC 809C.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CHAO, THERESA	FACILITY NUMBER: 434409289
	VISIT DATE: 01/09/2025

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The Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Exit interview conducted and report was reviewed with licensee, Therea Chao.

the licensee also confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A Notice of Site Visit was given and must remain posted for 30 days

The report was discussed and verbally translated into Mandarin during the exit interview with Licensee, Therea Chao.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025

LIC809 (FAS) - (06/04)

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