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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417029
Report Date: 05/31/2022
Date Signed: 05/31/2022 03:10:52 PM


Document Has Been Signed on 05/31/2022 03:10 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:SAMUELS, YUEHHUANGFACILITY NUMBER:
434417029
ADMINISTRATOR:YUEHHUANG SAMUELSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 623-8789
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY:14CENSUS: 1DATE:
05/31/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Yuehuang SamuelsTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Oscar Huang conducted an announced prelicensing inspection and met with Yuehhuang Samuels, Applicant for a small Family Child Care Home license. LPA observed one daycare infant at home.

The adults that reside in the home is applicant only. Days and hours of operation will be Monday - Friday from 8:30 AM to 6:30 PM. Applicant has completed her Preventative Health and Safety Child Care Training which includes an hour of nutrition & one hour lead poisoning prevention on 03/13/2022, and a copy of the certifications are on file. Applicant's CPR and First Aid certifications are current and expire on 03/2024. Applicant rents the home and a copy of lease agreement & landlord notification are on file. LPA reminder Applicant if she did not purchase liability insurance, she will need to issue affidavit regarding liability insurance for her Family Child Care Home to the parent of child in care.

The Applicant agreed to give LPA a tour of the home both indoor/outdoor during today's inspection. The entire home was inspected for health and safety hazards. LPA observed no stairs inside the home. The main area of the home is used for the day care are Living Room, Bedroom #1 & #2, and Bathroom #2, kitchen. LPA observed no fireplace and open face heater. Off limits areas inside the home: laundry & bathroom #1. LPA observed 3 functioning combined smoke/carbon monoxide detectors, and a full charged 3A40BC fire extinguisher. Off limits outdoor is the behind the side yard gate. LPA advised Applicant that whenever the climb structure is installed, softpad shall be placed on the ground around it to absorb falls. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA observed no bodies of water. Applicant stated there is no weapons & pets at home.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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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: SAMUELS, YUEHHUANG
FACILITY NUMBER: 434417029
VISIT DATE: 05/31/2022
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Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, drop side cribs, and baby walkers, bouncers, excer-saucers, jumpers etc. are not allowed in Family Child Care Homes. Applicant was advised to keep temperature within 68-85 degrees.

A review of staff records on today indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Applicant 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 violated.

LPA 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. LPA 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 they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

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



LPA discussed Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Applicant has completed her child care general &provider training on 3/29/2022 & 3/30/2022 , and copy of the certifications are on file.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: SAMUELS, YUEHHUANG
FACILITY NUMBER: 434417029
VISIT DATE: 05/31/2022
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Forms of discipline were discussed with Applicant. 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. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

LPA discussed SB 792 Immunization Requirement with Applicant. LPA observed appropriate records and physician notes for immunization against measles, pertussis, and influenza for Licensee in file. LPA reviewed COVID-19 infection prevention guidance & self-assessment with Applicant including the plans in place to protect and to support staff &children, as well as essential protective equipment and supplies, cleaning & hygiene implementation, arrival procedures, health screening & social distancing practices and meal times.

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.

LPA 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.

LPA advised Applicant that beginning January 1, 2019, AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families.



LPA conducted an exit interview, reviewed the report, and advised the Applicant, Yuehhuang Samuels that her small Family Child Care Home License Application is now pending on the management approval.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC809 (FAS) - (06/04)
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