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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416293
Report Date: 04/11/2023
Date Signed: 04/11/2023 04:03:59 PM

Document Has Been Signed on 04/11/2023 04:03 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:FU, DUXIANGFACILITY NUMBER:
434416293
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
04/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Duxiang FuTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang conducted an unannounced annual and a capacity increase request visit to the facility today. Licensee has been licensed as a small Family Child Care Home since January 17, 2021 at the same location, and is thus eligible to apply for the capacity increase. LPA met with Licensee Duxiang Fu and explained the nature of today's visit to her. LPA also observed 1 day care preschoolers & 3 infants in the home during today's visit. Days and hours of operation are Monday - Friday from 8:30 AM to 6:30 PM. The adults that reside in the home are the Licensee and her husband.

A review of staff records on 04/11/2023 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violate

LPA observed Licensee has current CPR and First Aid certifications which were expired 12/2022. 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 02/13/2023. LPA reviewed 4 children files. LPA observed Notification of Parents’ Rights is in each child’s file, missing the infant 15 min. sleeping check logs under 2 years old for all 3 infants, as well as missing an individual infant sleeping plan for an infant under 1 year old. Also, two of the children in care were missing immunization records and updates in form PM 286.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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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: FU, DUXIANG
FACILITY NUMBER: 434416293
VISIT DATE: 04/11/2023
NARRATIVE
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Licensee's Mandated Reporter Training is current. Licensee's copies of immunization records are also on file. The facility carries liability insurance under Acord.

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 states that she does not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time.

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-and-resources/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 Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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/childqanda.htm
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: FU, DUXIANG
FACILITY NUMBER: 434416293
VISIT DATE: 04/11/2023
NARRATIVE
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A fire clearance granted from the Santa Clara County Fire Department was received on 3/28/2023: 1. Approved day care areas highlighted w green on sketch forms. 2. Garage and areas no highlighted w green on sketch forms are not approved for day care use.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.



To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.

Based on today's inspection, LPA advised licensee that a large Family Child Care Home license will be approved pending on submitting the following items tothe office to clear deficiencies prior to the POC due dates and the management approval:

1. Copies of licensee's current CPR & first aid certification.
2. Infant 15 minutes sleeping log for infants under 24 months old in care.
3. Individual Infant Sleeping plan for an infant under 12 months old in care.
4. Current immunization records for 2 infants in care


Four deficiencies 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, Duxing Fu.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/11/2023 04:03 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 04/11/2023 at 03:48 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: FU, DUXIANG
FACILITY NUMBER: 434416293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

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
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Based on record review, the licensee did not comply with the section cited above by missing infant sleeping 15 min check which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2023
Plan of Correction
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Licensee agreed to submit the missing records to the office by the POC due date.
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as licensee's certifications had expired on 12/2022 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/25/2023
Plan of Correction
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Licensee agreed to submit the renew certifications to the office by the POC due date.
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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 04/11/2023 04:03 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 04/11/2023 at 03:48 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: FU, DUXIANG
FACILITY NUMBER: 434416293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by missing two childfen in care immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2023
Plan of Correction
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Licensee agreed to submit the missing records to the office by the POC due date.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by missing the plan for an infant under 12 months old which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/18/2023
Plan of Correction
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Licensee agreed to submit the missing records to the office by the POC due date.
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: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
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