434411751-10-25-2024-07-CC-LHUG-DADMA8-20241025092552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411751
Report Date: 10/23/2024
Date Signed: 10/25/2024 09:27:20 AM

Document Has Been Signed on 10/25/2024 09:27 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:	LIN, NA		FACILITY NUMBER:	434411751
ADMINISTRATOR/ DIRECTOR:	LIN, NA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 666-1181
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 12	DATE:	10/23/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:28 PM
MET WITH:	Lin, Na		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kate Huang and Licensing Program Manager (LPM) Gladys Kuizon conducted an unannounced Annual inspection today and met with licensee, Lin, Na.

12 children are present including 4 infants. LPA and LPM observed 2 assistants working here as full time teachers.

During nap time, LPA observed that 2 infants are sleeping in the separate cribs with loose blankets. LPA observed that one infant who is 3 months old is sleeping in the car seat.

LPA checked the carbon monoxide detector, smoke detector and fire extinguisher and all can work.

The home is kept clean and orderly, with heating and ventilation for safety and comfort. The home provides safe toys, play equipment and materials.

For outside yard, LPA observed small part of the fence is leaning. Licensee stated that the neighbor already asked the real property owner to fix it but the landlord refused to fix it. No body of water is accessible in the yard.

LPM reviewed the three staff records (S1-S3). S2 does not have required immunization record.

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.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Linke Huang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

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 10/25/2024 09:27 AM - It Cannot Be Edited

Created By: Linke Huang On 10/23/2024 at 03:50 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: LIN, NA	FACILITY NUMBER: 434411751
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102425(b)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. 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 because LPA observed that two infants are sleeping under loose blankets in the crib which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2024
	Plan of Correction
1 2 3 4	Licensee removed the loose blankets after the inspection. Licensee to submit a written plan of correction.

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:

Linke Huang

LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 10/25/2024 09:27 AM - It Cannot Be Edited

Created By: Linke Huang On 10/23/2024 at 03:50 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: LIN, NA	FACILITY NUMBER: 434411751
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(h)

Infant Safe Sleep

Car seats shall only be used for transportation purposes and shall not be used for sleeping. 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 because one infant is sleeping in the car seat during nap time with an assistant which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/24/2024
	Plan of Correction
1 2 3 4	LPA to submit a written plan of correction. Licensee removed the child from the car seat during the inspection.

Type B

Section Cited

HSC

1597.622(c)

Administration of Child Day Care Licensing

(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above because one staff (S2) does not have required immunization record in file which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/22/2024
	Plan of Correction
1 2 3 4	Licensee to submit a written plan of correction, Licensee to provide S2's required immunization record.

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:

Linke Huang

LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: LIN, NA	FACILITY NUMBER: 434411751
	VISIT DATE: 10/23/2024

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The licensee said that they do not provide medicine to children. 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/.

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.

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

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.

Deficiencies were cited today. Licensee was provided LIC 9224 and informed that a copy of the Type A violation must be provided to parents of currently enrolled children and all new enrollments for the next 12 months. A signed copy of the LIC 9224 must be kept in the children's files.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee in Mandarin.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Linke Huang
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2024

LIC809 (FAS) - (06/04)

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