434416868-3-12-2025-07-CC-MMOO-DEPPG2-20250312111736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416868
Report Date: 03/12/2025
Date Signed: 03/12/2025 11:18:37 AM

Document Has Been Signed on 03/12/2025 11:18 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	HSAW, ASHLEY		FACILITY NUMBER:	434416868
ADMINISTRATOR/ DIRECTOR:	ASHLEY HSAW		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 793-1893
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 2	CENSUS: 2	DATE:	03/12/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:53 AM
MET WITH:	Ashley Shaw		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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 March 12, 2025 at 8:53 AM, Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Annual Random Inspection. LPA met with Licensee's mom/helper (S1). An infant was also present in the home. LPA was granted access to the home by S1. Licensee, Ashley Hsaw, arrived few minutes later and met with LPA. The Licensee received the Entrance Checklist (LIC 126). LPA observed all required postings. The daycare is open Monday thru Friday from 8:30 AM to 6:30 PM. There are no active waivers or exceptions for this facility. Licensee stated that she is the only adult residing in the home. Another daycare child arrived during the inspection. LPA obtained a copy of current children's roster. Fire/disaster drill was completed on February 12, 2025. LPA observed a fully charged 2A10BC fire extinguisher installed in the kitchen. LPA observed functioning smoke and carbon monoxide detector and glass covered fireplace. Licensee stated that there are no weapons or firearms in the home. 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 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. Licensee, 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. Continuation on next pages:

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HSAW, ASHLEY	FACILITY NUMBER: 434416868
	VISIT DATE: 03/12/2025

NARRATIVE

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Off limit areas inside the home: Bedroom #3, Bathroom 2, kitchen, and garage. LPA observed that the home is clean and orderly. Cleaning products, sharp objects, and other hazardous items were stored inaccessible to children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. There are no off limit areas outside the home. No bodies of water were observed.

LPA reviewed two (2) children's files during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), Affidavit Regarding Liability Insurance (LIC 282), sleep log for children under 2 years old, Individual Infant Sleeping Plan (LIC 9227) for children under 12 months old, and Immunization Records.

LPA reviewed a helper's file (S1) for the following records: Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunizations, fingerprint clearance, TB test, and required training. S1's fingerprint clearance is not associated to the facility. Licensee stated that S1 has been working in the home since January 20, 2025. Licensee has the required immunizations and current Pediatric CPR/First Aid certifications with an expiration date of April 5, 2026. Licensee's Mandated Reporter Training expires on January 20, 2026. LPA reminded licensee that Mandated Reporter training must be renewed by all staff every 2 years.

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.

Continuation on next pages:

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HSAW, ASHLEY	FACILITY NUMBER: 434416868
	VISIT DATE: 03/12/2025

NARRATIVE

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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/process.

Licensee, Ashley Hsaw, 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.

As a result of this inspection, Type B deficiency was cited on the following page.

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

During the exit interview, the Licensee, Ashley Hsaw, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A Notice of Site Visit was given to Licensee, Ashley Hsaw, and must remain posted for 30 days.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/12/2025 11:18 AM - It Cannot Be Edited

Created By: Marilou Monico On 03/12/2025 at 10:41 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: HSAW, ASHLEY	FACILITY NUMBER: 434416868
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102370(d)(2)

Criminal Record Clearance - (d) 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). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, S1's fingerprint clearance is not associated to the facility which poses a potential health, safety or personal rights risk to persons in care. A civil penalty of $500 was assessed.
	POC Due Date: 03/14/2025
	Plan of Correction
1 2 3 4	Licensee states that she will submit a completed Criminal Background Clearance Transfer Request (LIC 9182) along with S1's identification to Licensing by 03/14/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Marilou Monico

LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025

LIC809 (FAS) - (06/04)

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