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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417296
Report Date: 09/03/2024
Date Signed: 09/03/2024 12:34:23 PM

Document Has Been Signed on 09/03/2024 12:34 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ZHAO, SHUANGFACILITY NUMBER:
434417296
ADMINISTRATOR/
DIRECTOR:		ZHAO, SHUANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 966-1086
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 12DATE:
09/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Shuang ZhaoTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Mandeep Kaur and Andy Yang conducted an unannounced case management inspection. LPAs met with Licensee, Shuang Zhao and discussed the purpose of the inspection. LPAs toured the indoor and outdoor areas of the Facility with licensee. Upon arrival, present were licensee, an assistant(S1) and licensee's child.

LPA reviewed three (3) staff files and twelve (12) children files during today's inspection. Staff records reviewed include Employee Rights, Statement Acknowledging Requirement to Report Child Abuse, Health Screening Report with TB Clearance, Immunizations (Measles, Pertussis, and Influenza) and required training. Based on records review and interview, 3 of 3 staff are missing required Mandated Reporter Training, Staff (S1) is missing TB test and staff(S3) is missing immunizations records.. LPAs reminded Licensee that the Mandated Reporter Training shall be renewed by all staff every two years and staff immunizations records need to available for review.

Two Type B deficiencies were issued during today's inspection on attached 809-D. Appeal rights provided to Licensee, Shuang Zhao.

Exit interview conducted with Licensee Shuang Zhao. A notice of site visit was issued and must remain
posted for 30 days.


SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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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Document Has Been Signed on 09/03/2024 12:34 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 09/03/2024 at 11:38 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: 09/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/17/2024
Section Cited
HSC
1596.8662

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1596.8662(b) (1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
This requirement is not met as evidenced by:
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Licensee agreed to submit the proof of the completed Mandated Reported training (AB1207) certificates for all the staff at the facility by POC due date to the department.
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Based on records review and interview, the licensee did not comply with the section cited above by not having 3 out of 3 staff completed required mandated reporter training which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/17/2024
Section Cited
HSC1597.622

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1597.622 (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
This requirement is not met as evidenced by:
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Licensee stated that she will submit the proof of the immunizations records for staff (S1 & S3) by POC due date to the department.
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Based on records review and interview, licensee did not comply with the section cited above by not having required mmuniziations records on file for staff (S1 & S3) on for review: staff (S1) is missing TB test which poses a potential health, safety or personal rights risk to persons in care.
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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:Belinda Devall
LICENSING EVALUATOR NAME:Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


LIC809 (FAS) - (06/04)
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