434416868-1-29-2024-07-CC-MMOO-CZXRS3-20240129121603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416868
Report Date: 01/29/2024
Date Signed: 01/29/2024 12:16:18 PM

Document Has Been Signed on 01/29/2024 12:16 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	HSAW, ASHLEY		FACILITY NUMBER:	434416868
ADMINISTRATOR:	ASHLEY HSAW		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 793-1893
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	01/29/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:04 AM
MET WITH:	Ashley Hsaw		TIME COMPLETED:	12:30 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	On January 29, 2024 at 9:04 AM, Licensing Program Analysts (LPAs) Marilou Monico and Martha Jimenez-Villanueva conducted an announced Prelicensing Inspection. LPAs met with Applicant, Ashley Hsaw, and explained the purpose of today's visit. Per Applicant, she is the only adult residing in the home. The home is a one storey with three bedrooms and two bathrooms. Days and hours of operation will be Monday - Friday from 8:30 AM to 6:30 PM. Applicant has completed the Preventative Health and Safety Training including Nutrition and a copy of the certification is on file. Applicant is missing proof of completion of Lead Poisoning training. Applicant's CPR and First Aid certifications are current and expire on 05/09/24. Applicant completed the Mandated Reporter Training on 01/20/24. Applicant's immunizations in measles, pertussis, and flu are on file. Applicant states that she will use the Affidavit Regarding Liability Insurance form to inform parents that she does not have daycare insurance. The Applicant submitted proof of control of property to Licensing. Because the Applicant leases the home, proof of landlord notification is required. The Applicant submitted the Property Owner/Landlord Notification form (LIC 9151) that the applicant confirms was provided to the property owner/landlord. LPAs toured the indoor and outdoor areas of the home during today's inspection. LPAs observed: fully charged 2A10BC fire extinguisher, glass covered fireplace, gated kitchen, functioning smoke and carbon monoxide detectors. Off limit areas inside the home are: Bedroom #3, Bathroom 2, kitchen, and garage. The home is clean and orderly, with heating/air conditioning, and ventilation for safety and comfort. There is sufficient toys, supplies, and equipment for the day care children. Applicant states that there are no weapons in the home. There are no off limit areas outside the home. LPAs did not observe bodies of water. Continuation on next pages:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HSAW, ASHLEY	FACILITY NUMBER: 434416868
	VISIT DATE: 01/29/2024

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

Forms of discipline to be used by Applicant: talking to children, positive re-enforcement, and redirection. Cleaning products, toxic agents, medications, and sharp objects were inaccessible to children. LPAs reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.

Applicant understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPAs informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

Applicant, Ashley Hsaw, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

LPAs discussed the requirements of Assembly Bill(AB) 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPAs discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

LPAs discussed the safe sleep regulations with applicant 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. LPAs also informed Applicant 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 she registers all infant devices with the CPSC to be notified of any recalls on her purchased equipment.
Continuation on next pages:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: HSAW, ASHLEY	FACILITY NUMBER: 434416868
	VISIT DATE: 01/29/2024

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

LPAs reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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.

PIN 22-02-CCP - Best Practices Related to the Provision of Incidental Medical Services in Child Care Center and Family Care Homes was provided to Applicant.

On this date, 12/28/23, the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California Megan's Law. No registered sex offenders found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. 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.

Continuation on next page:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: HSAW, ASHLEY	FACILITY NUMBER: 434416868
	VISIT DATE: 01/29/2024

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

Fire clearance was granted on 01/24/24.

A license for a Large Family Child Care Home will be approved upon receipt of the following:
1) Updated Emergency Disaster Plan (LIC 610A) with permission letter from temporary relocation sites.
2) Proof that Applicant completed the Lead Poisoning training.
3) Proof that the furnace closet located in the hallway is inaccessible to children.

Exit interview conducted and report was reviewed with the Applicant, Ashley Hsaw.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4