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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416349
Report Date: 10/18/2023
Date Signed: 11/13/2023 11:35:13 AM

Document Has Been Signed on 11/13/2023 11:35 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:WANG, CHI MEIFACILITY NUMBER:
434416349
ADMINISTRATOR:WANG, CHI MEIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 933-8762
CITY:SUNNYVALESTATE: CAZIP CODE:
94086
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
10/18/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Chi Mei WangTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang met with licensee, Chi Mei Wang for an unannounced case management visit. LPA explained the nature of today’s inspection to licensee.

A review of staff records on 10/18/2023 indicates that one staff who requires caregiver background checks has received criminal record and child abuse index clearances or exemptions but was not associated with the facility. 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.

A type "B" 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, Chi Mei Wang.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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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Document Has Been Signed on 11/13/2023 11:35 AM - It Cannot Be Edited


Created By: Yangcheng Huang On 10/18/2023 at 10:54 AM
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: WANG, CHI MEI
FACILITY NUMBER: 434416349

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2023
Section Cited
CCR
102370(d)(2)

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Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 102370(j)
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Licensee to request a criminal record transfer of the helper prior to the POC due date.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for not requesting transfer of a criminal record of one helper prior to work which posed an potential health, safety or personal rights risk to persons in care.
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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: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023


LIC809 (FAS) - (06/04)
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