<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417296
Report Date: 03/27/2023
Date Signed: 03/27/2023 10:03:29 AM

Document Has Been Signed on 03/27/2023 10:03 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:ZHAO, SHUANGFACILITY NUMBER:
434417296
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
03/27/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Shuang ZhaoTIME COMPLETED:
10:20 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
Licensing Program Analyst (LPA) Oscar Huang conducted an unannounced case management visit to the home today. Licensee has requested to increase her licensed capacity to 14 children. Licensee has been licensed as a small Family Child Care Home since October 17, 2022 at the same location, and prior to obtain her license, Licensee was a fully qualified teacher working in a preschool center for over 7 months, and is thus eligible to apply for the capacity increase. LPA met with Licensee Shuang Zhao and explained the nature of today's visit to her. LPA also observed licensee's spouse and 5 day care childre (2 preschoolers and 3 infants in the home during today's visit. Days and hours of operation are Monday - Friday from 8:30 AM to 6:00 PM. The adults that reside in the home are the Licensee and her husband. LPA advised Licensee that her infant son will be accounted to her capacity when present during her operation hours.

A review of staff records on 03/27/2023 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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

LPA observed Licensee has current CPR and First Aid certifications which are expiring 03/2024. LPA observed a current roster of the children and a fire and disaster drills log which is to be done at least once every six months. The last drills were conducted on 01/16/2023.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ZHAO, SHUANG
FACILITY NUMBER: 434417296
VISIT DATE: 03/27/2023
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
LPA reviewed 5 children files, LPA observed Identification and Emergency Information, Notification of Parents’ Rights, Individual Infant Sleeping Plan for infant under 1 year old are in each child’s file, but 4 children's immunization records are missing and 3 infants missing 15 min. sleeping check logs infants under 2 years old.

Licensee's Mandated Reporter Training is current and on file. The facility carries liability insurance under Acord Insurance.

Supervision of children was discussed with Licensee, and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options. Licensee states that she does not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time.

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.

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
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ZHAO, SHUANG
FACILITY NUMBER: 434417296
VISIT DATE: 03/27/2023
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
A fire clearance granted from the Santa Clara Fire Department was received on 3/20/2023: fire clearance granted for 14 max capacity.

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.



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/inspection-process.

Based on today's inspection, LPA advised licensee that a Large Family Child Care Home license will be approved pending on submitting the following documents to the office and the management approval:

1. 15 minutes sleeping check logs for infants under 2 years old.
2. Most current immunization records for 4 enrolled children.

Two deficiency were 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, Shuang Zhao.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/27/2023 10:03 AM - It Cannot Be Edited


Created By: Yangcheng Huang On 03/27/2023 at 09:39 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: ZHAO, SHUANG
FACILITY NUMBER: 434417296

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2023
Section Cited
CCR
102418(g)

1
2
3
4
5
6
7
Immunizations: (g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to submit the most current immunization records of the 4 children in care to the office prior to the POC due date.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above that 4 of 5 children in care were missing immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
04/17/2023
Section Cited
CCR102425(j)(1)

1
2
3
4
5
6
7
Infant Safe Sleep: The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agree to submit the records to the office by the POC due date.
8
9
10
11
12
13
14
Based on record review, the licensee did not comply with the section cited above on missing 15 minutes sleeping check logs for all the infants which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4