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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416673
Report Date: 06/28/2021
Date Signed: 06/28/2021 11:48:43 AM

Document Has Been Signed on 06/28/2021 11:48 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CHI, LEWISFACILITY NUMBER:
434416673
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
06/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lewis ChiTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Joe Macias conducted an unannounced Annual Required (tool kit #1)/ Increase of Capacity Inspection. LPA was greeted and granted entrance by the Lewis Chi. The Licensee recently submitted an application for an increase of capacity. The Licensee is currently licensed to provide care for up to 8 children, and wishes to obtain a large license to provide care for up to 14 children. The purpose of today’s inspection is to ensure the home is in compliance with Title 22 California Code of Regulations. Prior to today's inspection LPA Macias received an approved fire clearance from Sunnyvale Fire Prevention. The STD 850 states day care use not permitted in kitchen or detached garage. Todays census is 5 (5 preschool age). The Licensee and two roommates Maria Dimanova, and Ivan Canas are the only adult who reside in the home. The day care hours of operation are Monday - Friday, 8am - 6:30pm. The Licensee's CPR and First Aid are current, and expire September 2021.

LPA toured the indoor and outdoor areas of the home during today's visit. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's visit. LPA Macias reviewed the children files and observed all required documents present. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the children in care. The home is orderly, and safe for the day care children. LPA did not observe a wall heater in the home (central heat). Off limit areas of the home: all bedrooms, office, kitchen, and detached garage.

LPA observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors, and no bodies of water. The Licensee states that he does not have weapons in the home. All detergents, cleaning compounds, poisons, medications, and other similar items are out of reach and inaccessible to children. Licensee states that she does not administer medications at this time.

Supervision of children was discussed with the Licensee and he understands that he must be present in the home during day care hours to ensure that the children are safe and supervised at all times. The Licensee understands his current capacity options and he understands that he cannot have more than 8 children in the home at any time (until large license is approved). LPA provided the Licensee with the ratio/capacity chart for his reference. The Licensee states that he does not transport children; however he understands that children cannot be left in parked vehicles unattended any time.

LPA observed staff immunization records on file.

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Joseph Macias
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CHI, LEWIS
FACILITY NUMBER: 434416673
VISIT DATE: 06/28/2021
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LPA also went over safe sleep for infants:

· Always place infants on their backs for sleeping.


· Use a tight-fitting sheet on the crib or play yard mattress.
· Do not hang any items from the crib or above the crib.
· Keep all items out of the crib or play yard.
· Pacifiers may be used as long as they do not have items attached to them.
· Infants should not be swaddled or have any items covering them while sleeping.
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.

A review of staff records on June 28, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. A $500 immediate civil penalty. An ongoing $100 per day per violation continues until the violation(s) is corrected. LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and licensee understands the requirements.

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: http://www.ada.gov/childqanda.htm

The Licensee has completed the Mandated Reporter Training.

No deficiencies cited, exit interview conducted, and a copy of this report was provided to the Licensee. LPA Macias advised the Licensee that the large license will be granted pending management approval.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Joseph Macias
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC809 (FAS) - (06/04)
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