434417421-5-14-2024-07-CC-SCHN-D58VMX-20240513163416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417421
Report Date: 05/13/2024
Date Signed: 05/14/2024 06:43:49 AM

Document Has Been Signed on 05/14/2024 06:43 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:	MA, QIAN		FACILITY NUMBER:	434417421
ADMINISTRATOR/ DIRECTOR:	QIAN MA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 464-3277
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94089
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	05/13/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Qian Ma		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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	Page 1. On 5/13/24 Licensing Program Analyst (LPA) Sheena Chin conducted a scheduled Pre-Licensing inspection. LPAs met with the applicant Qian Ma. The applicant submitted an application for a large Family Child Care Home on 4/2/24. The applicant had at least one year of working experiences as a teacher in a licensed center. The facility will operate from 8:15am to 5:45pm Monday through Friday and serve children from 15 months to 5 years of age. The applicant stated that she rented this property. The co-singer of the lease provided a statement that she would not enter into the property during child care operation hours. Observations The applicant and LPA toured inside and outside of the facility. The facility is a one-story house. Off limits are bedroom #1, bedroom #2, bathroom #1, kitchen, garage and the storage room in the back yard. The fireplace as sealed and the wall heating unit in the child care area was screened. Cleaning supplies were stored under the sink in the kitchen, inaccessible to children. There were a few toys. The applicant stated that she will purchase more age-appropriate toys. LPA advised the licensee to use the website of the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ for recalls for their purchases. There were no baby walkers observed during today's inspection. Applicant understands that baby walkers and smoking are prohibited in the facility. Fully charged fire extinguisher, 2A10BC, was placed in the living room. LPA discussed with the applicant that the fire extinguisher needs to be fully charged or replaced with a new one. Smoke/carbon monoxide detectors were working properly in the facility. The facility was granted fire clearance on 5/7/24. continue to page 2.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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

FACILITY NAME: MA, QIAN	FACILITY NUMBER: 434417421
	VISIT DATE: 05/13/2024

NARRATIVE

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Required Documents
The applicant has completed Pediatric First Aid/CPR (expires on 2/24/26), Preventative Health and Safety Training( completed 2/27/24). The applicant has proofs of immunization against pertussis, measles. The applicant stated that she’s willing to have the flu shot.

The applicant stated that adults residing at this facility include the applicant, and the tenant. The applicant stated that the property she rented used to be a small family child care home, which had been closed. The tenant stayed in the property since June 2023 and filled out background clearance transfer request from the previous closed facility to her child care home. A review of staff records indicated that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

The applicant has a certificate of mandated reporter training, expired on 7/6/25. The applicant provided the lease agreement as proof of control of the property. The applicant and her friend cosigned the lease agreement. Her friend provided a statement, indicating that she would not enter into the property during child care operating hours. Because the applicant rents/leases the home, proof of landlord notification is required. The Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149). Without this consent, the applicant understands that, once licensed, they can operate with a maximum capacity of 12 children. If property owner/landlord consent is obtained in the future, the applicant is advised that a new Application for a Family Child Care Home License (LIC 279) must be submitted with a change of capacity fee of $25, to increase the capacity and provide care to 14 children.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

LIC809 (FAS) - (06/04)

Page: 2 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MA, QIAN	FACILITY NUMBER: 434417421
	VISIT DATE: 05/13/2024

NARRATIVE

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Required documents.
The applicant stated that she would purchase liability insurance, and understood that if she does not provide it, she needs to have each parent sign LIC282, affidavit regarding liability insurance for family child care home. LPA advised the applicant that the facility would be considered as a small family child care if without hiring a helper.

LPA reviewed with applicant the LIC126, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

Discussions
The applicant understood that children's personal rights should not be violated, including no corporal punishment. LPA discussed with the applicant about isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries. LPA informed the applicant that fire/disaster drills must be practiced at least once every 6 months and documented. LPA discussed the safe sleep regulations with the applicant 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 applicant 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. 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

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

FACILITY NAME: MA, QIAN	FACILITY NUMBER: 434417421
	VISIT DATE: 05/13/2024

NARRATIVE

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Information
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

The applicant was informed of the MyChildCarePlan.org site, 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.

On this date, 4/3/24, The California Attorney General- Megan's Law Website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

A fire clearance granted from the Sunnyvale Fire Department was received on 5/7/24: Fire clearance granted. Zero to 14 kids was confirmed to be at with licensing. Off limit areas are garage, kitchen, two back bedrooms, and back bathroom. Fire extinguisher good until 4/26/25.

Exit interview was conducted and the report was discussed and verbally translated into Chinese with applicant, Qian Ma. LPA advised the applicant that her large family child care home license is pending upon management review and approval.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Sheena Chin
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024

LIC809 (FAS) - (06/04)

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