434417419-8-13-2025-07-CC-SYUU-DKHMJ9-20250813093847

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417419
Report Date: 08/01/2025
Date Signed: 08/13/2025 09:39:17 AM

Document Has Been Signed on 08/13/2025 09:39 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	SONG, YI LIN		FACILITY NUMBER:	434417419
ADMINISTRATOR/ DIRECTOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY: 8	TOTAL ENROLLED CHILDREN: 6	CENSUS: 5	DATE:	08/01/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	YiLin Song		TIME VISIT/ INSPECTION COMPLETED:	11:45 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) Shine Yu met with Licensee, YiLin Song for an unannounced Annual/Random inspection and capacity increase request. LPA observed one adult assistant and five day care children (3 infants & 2 preschool) in the home during today's inspection. Licensee was operating within their capacity and ratio requirements. Licensee has been licensed as a small Family Child Care Home since 04/16/2024 and thus meet the one year minimum experience requirement to apply for the large Family Child Care Home License. LPA observed the required postings, including the facility license, Emergency Disaster Plan (LIC610) and Parents' Rights (PUB 393) on the wall of the living room. The last fire/disaster drill was completed on 04/24/2025. Days and hours of operation are Monday - Friday from 8:30 AM to 6:00 PM. Licensee and her spouse are the only adults residing in the home. There are no minor children residing in the home. Licensee has current CPR and First Aid certifications (exp: 02/27/27) on file. Licensee and one adult assistant have the required vaccines (MMR, Tdap, & flu - opt out). LPA reviewed a current Child Care Facility Roster and LPA reviewed 5 children's files (3 infants & 2 preschool) and the files were complete with the required forms, infant 15 minutes check sleep logs. Copy of lease agreement verifying control of property is on file. Licensee will submit Property Owner/Landlord Notification (LIC 9151) and a signed Property Owner/Landlord Consent (LIC 9149) forms to LPA. Continue on page 2

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Syhshyan Yu
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SONG, YI LIN	FACILITY NUMBER: 434417419
	VISIT DATE: 08/01/2025

NARRATIVE

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LPA toured the indoor and outdoor areas of the home with the Licensees during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly, and safe for the day care children. There are safe & age appropriate toys, play equipment, and materials for the children in the home. There are no stairs inside the home. Licensee has one wall heater inside the home that needs to be barricaded and licensee will provide proof to LPA. Off limit areas inside the home are: bedroom 1 & 3, and kitchen. Off limit areas outside the home: the back side area of the backyard.

LPA observed a fully charged 3A40BC fire extinguisher in the living room and working smoke/carbon monoxide detectors in the bedroom 2 and hall way. There is no bodies of water in home and play area is fenced in the backyard. Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children.

Licensee state that she provides all meals, fruits and snacks to the day care children.
Licensee understands that any food/drink brought from home shall be labeled with each child's name and properly stored. Licensee has a first aid kit in the home which includes a touch less thermometer. Licensee states that nobody smokes and they understands that smoking is prohibited in the home.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-andresources/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.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Syhshyan Yu
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025

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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SONG, YI LIN	FACILITY NUMBER: 434417419
	VISIT DATE: 08/01/2025

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Licensee stated there is no medication provided in the facility. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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/resources/child-care-centers/.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

The Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Exit interview conducted in Mandarin and report was reviewed with the Licensee, YiLin Song.

No deficiencies issued during today's inspection. A Notice of Site Visit was given and must remain posted for 30 days.

A large Family Child Care Home license will be reviewed and final approved by manager upon completion of the following:

1. Updated LIC 9149 Property Owner / Landlord consent - family child care home has been received.
2. Updated LIC 9151 Property Owner / Landlord Notification - family child care home has been received.
3. proof of barricaded wall heater has been received.

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Syhshyan Yu
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025

LIC809 (FAS) - (06/04)

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