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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417341
Report Date: 03/14/2024
Date Signed: 03/14/2024 03:25:05 PM

Document Has Been Signed on 03/14/2024 03:25 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SAMUELS, YUEHHUANGFACILITY NUMBER:
434417341
ADMINISTRATOR:SAMUELS, YUEHHUANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 609-0052
CITY:SUNNYVALESTATE: CAZIP CODE:
94085
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
03/14/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Yuehhuang SamuelsTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang met with licensee, Yuehhuang Samuels for an unannounced case management visit. LPA explained the nature of today’s inspection to licensee.

A review of staff records on 03/14/2024 indicates that one staff who requires caregiver background checks did not obtain criminal record and child abuse index clearances or exemptions to be transferred and therefore was not associated with the facility. 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 violated.

In addition, each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent or guardian, and the name and telephone number of the child's physician. This roster shall be available to the licensing agency upon request. LPA did not observe a current roster during the visit.

Two type "B" deficiencies 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, Yuehhuang Samuels.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2024
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 03/14/2024 03:25 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 03/14/2024 at 12:44 PM
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: SAMUELS, YUEHHUANG
FACILITY NUMBER: 434417341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
102370(d)

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Criminal Record Clearance: 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.
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Licensee agreed to submit criminal clearance record transfer request within the POC due date.
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This requirement was not met as evidenced by: LPA observed there was a helper who was finger printed with licensee's closed facility number, not been associated with the current facility during the time of inspection. This poses a potential safety & health risk to children in care.
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Type B
03/15/2024
Section Cited
CCR102417(g)(8)

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Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
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Licensee agreed to submit a current roster prior to the POC due date.
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This requirement was not met as evidenced by: LPA observed that the facility did not maintained a current roster during the time of inspection. This poses a potential safety & health risk to children 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024


LIC809 (FAS) - (06/04)
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