<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415392
Report Date: 04/22/2024
Date Signed: 04/22/2024 03:04:39 PM

Document Has Been Signed on 04/22/2024 03:04 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SHANG, ANN IFACILITY NUMBER:
434415392
ADMINISTRATOR/
DIRECTOR:		ANN I SHANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 992-5576
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
04/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Ann ShangTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Oscar Huang met with Licensee, Ann Shang for an unannounced annual. LPA explained the nature of today’s inspection to Licensee. Present were licensee and two helpers, 12 preschoolers and an infant during today's inspection which is over the capacity of the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home. Days and hours of operation are Monday to Friday, 8:30am to 6:00pm. The adults that reside in the home is licensee only.

A review of staff records on 04/22/2024 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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 conducted CARE Tools for this annual inspection, which include Physical Plant, Care and Supervision, Facility Administration, Records, Staffing Ratio and Capacity, Personnel Rights for compliance with all licensing statutes, regulations, and interim licensing Standards, and results were documented on the tool.

LPA observed licensee & her helper have current CPR and First Aid certifications which are expiring 3/2026. LPA observed a current roster of the children and a fire and disaster drills log which is to be done at least once every six months. The last drills were conducted on 1/10/2024. LPA reviewed all 13 children files. Immunization records are maintained and up-to-date. Licensee was advised to update the records in CDPH 286. LPA observed Notification of Parents’ Rights is in each child’s file. But an infant 15 min sleeping check logs were missing.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SHANG, ANN I
FACILITY NUMBER: 434415392
VISIT DATE: 04/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Supervision of children was discussed with Licensee, and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options. Licensee stated that they do not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When IMS is provided, a Plan of Operation that includes IMS shall be submitted to the Department and on file. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

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.

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

AB633 Parent Notification is required. This report along with LIC809-D page shall be provided to all parents of children currently enrolled and any future children being enrolled for the next 12 months per AB633 requirements.

A type A deficiency and a type B deficiency were cited. A notice of site visit was given and must remain posted for 30 days. The report was discussed and verbally translated into Chinese during the exit interview with Licensee, Ann Shang.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/22/2024 03:04 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 04/22/2024 at 02:36 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: SHANG, ANN I
FACILITY NUMBER: 434415392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

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 as LPA observed total of 13 children were in care (12 preschoolers and an infant) that was over the capacity which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
1
2
3
4
Licensee needs to immediately reduce the number of children to 12 in care, no more than 4 infants of them. Licensee needs to submit CCL a written statement indicating what steps the Licensee is going to implement to ensure that she is operating within the required capacity of her Large Family Child Care License by the POC due date.
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:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/22/2024 03:04 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 04/22/2024 at 02:36 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: SHANG, ANN I
FACILITY NUMBER: 434415392

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

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 that there is no sleeping check records for an infant under 24 months old which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/06/2024
Plan of Correction
1
2
3
4
Licensee agreed to sumbit the missing records to the office prior to the POC due date.
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:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
Page: 4 of 4