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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415163
Report Date: 12/10/2024
Date Signed: 12/13/2024 04:16:54 PM

Document Has Been Signed on 12/13/2024 04:16 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:TAN, KRISTINAFACILITY NUMBER:
434415163
ADMINISTRATOR/
DIRECTOR:		TAN, KRISTINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
4088968686
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
12/10/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Kristina TanTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA), Shine Yu, conducted an unannounced Annual Inspection 8:40 am and was greeted by and met with the Licensee, Kristina and her mom

LPA observed the required posted materials, including the Facility License, Emergency Disaster Plan (LIC 610), Parents' Rights Poster (PUB 393) and Personal Rights (LIC 613A). Facility's operating days and hours are Monday to Friday 8:00AM to 5:00 PM. LPA observed a current Children's roster. Present are licensee, her mom, and 6 children, including 2 under 2 years old. By 10:40 am, all 14 children are present. Another assistant Cynthia also present.

LPA reviewed a random selection of children's file and observed that 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: Employee Rights (LIC9052), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza.

LPA toured the facility. Off limits areas inside the home, is kitchen, living room and the four bedrooms and garage. There are age-appropriate toys for children. Licensee stated there is no firearm in the facility. There is no body of water observed outside of play yard. LPA observed one of the crib is full of toys. LPA stated the crib should be free of objects. Licensee removed the toys right away. 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: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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 2
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: TAN, KRISTINA
FACILITY NUMBER: 434415163
VISIT DATE: 12/10/2024
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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.

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.

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 the licensee Kristina.

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


No deficiencies issued during today’s inspection.

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

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
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