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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416344
Report Date: 12/06/2022
Date Signed: 12/06/2022 11:33:04 AM

Document Has Been Signed on 12/06/2022 11:33 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MA, JIEFACILITY NUMBER:
434416344
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
12/06/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jie MaTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA), Oscar Huang, conducted an unannounced Plan of Correction (POC) to the Facility today. LPA met with licensee Jie Ma, and explained the nature of today's visit to her. The purpose of the inspection is to review POCs for deficiencies that were cited on 11/21/2022. Present during today's inspection were licensee, a helper, 3 infants and 2 preschoolers.

The facility was issued a "Type A" deficiencies on 11/21/2022 for over capacity. The Plan of Correction was due on 11/30/2022.

LPA observed the Notice of Site Visit, LIC 9099 & LIC 9099-D reports which were issued 11/21/2022 were posted on wall next to the facility entrance door. Licensee submitted a plan of correction statement to CCL on 11/21/2022, prior to POC due date, LPA also observed that the Acknowledge of Receipt of Licensing Reports were signed by the parents of children in care and kept in each child's records.

LPA concludes that the the facility has completed its required plan of corrections and the deficiencies are thus cleared as of today's visit.

No deficiency was 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, Jie Ma.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2022
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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