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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417358
Report Date: 01/11/2024
Date Signed: 01/11/2024 10:49:11 AM

Document Has Been Signed on 01/11/2024 10:49 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:PAN, YANGFACILITY NUMBER:
434417358
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 3CENSUS: 1DATE:
01/11/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Yang PanTIME COMPLETED:
11:05 AM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang conducted an unannounced case management visit to the home today. Licensee has requested to increase her license capacity to 14 children. Licensee was licensed as a large Family Child Care Home since October, 2016 at 1859 Anne Marie Court, San Jose and is thus eligible to apply for the capacity increase. LPA met with Licensee Yang Pan and explained the nature of today's visit to her. LPA also observed licensee's spouse and an infant in the home during today's visit. Days and hours of operation are Monday - Friday from 8:00 AM to 6:00 PM. The adults that reside in the home are the Licensee and her husband.

A review of staff records on 01/11/2024 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 and her husband have current CPR and First Aid certifications which are expiring 06/2025. 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 08/18/2023. Licensee and her husband have documented proof of immunity against Measles, Pertussis, proof of cleared Tuberculosis, and statement of not taking Influenza in this season. Their certifications of completion of the AB1207 Mandated Reporter Training exp 9/18/2024.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
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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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: PAN, YANG
FACILITY NUMBER: 434417358
VISIT DATE: 01/11/2024
NARRATIVE
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LPA reviewed all 3 children files, LPA observed Identification and Emergency Information, Notification of Parents’ Rights, but missing 15 min. sleeping check logs for infants under 2 years old and missing Individual Infant Sleeping Plan for an infant under 1 year old when enrolled.

Supervision of children was discussed with Licensee, and she understood 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 PIN 22-02-CCP. IMS is not provided by the facility, when provides, the Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PAN, YANG
FACILITY NUMBER: 434417358
VISIT DATE: 01/11/2024
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

A fire clearance granted from the San Jose Fire Department was received on 01/08/2024: Hosted by Yang Pan. All fire protection systems and exiting are in compliance. Garage, staff room, main bedroom, private bedroom, office and kitchen are off limits. Yard area, baby room, classroom, school area and guest room are okey for children.

During the exit interview, licensee, Pan Yang confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS on 1/11/2024.

Two type B deficiencies were cited. Based on today's inspection, LPA advised Licensee/Applicant that a large Family Child Care Home license will be approved pending on the management final review & approval and submitting the following documents to the office:

1. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] for infant when enrolled under 12 month old.
2. 15 minutes sleeping check logs for infants under 2 years old.

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, Yang Pan.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/11/2024 10:49 AM - It Cannot Be Edited


Created By: Yangcheng Huang On 01/11/2024 at 10:14 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: PAN, YANG
FACILITY NUMBER: 434417358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/25/2024
Section Cited
CCR
102425(c)

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Infant Safe Sleep: An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.
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Licensee agreed to submit the missing infant sleeping plan record to the office prior to the POC due date.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above by missing the plan for an infant under 12 months old which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/25/2024
Section Cited
CCR102425(j)(1)

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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:
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Licensee agree to submit the 15 min. sleeping check records to the office prior to the POC due date.
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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.
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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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024


LIC809 (FAS) - (06/04)
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