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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417452
Report Date: 01/31/2025
Date Signed: 02/04/2025 09:46:12 AM

Document Has Been Signed on 02/04/2025 09:46 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:MOU, ZHIYIFACILITY NUMBER:
434417452
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
01/31/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:49 AM
MET WITH:ZhiYi MouTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA), Shine Yu conducted an announced Pre-licensing inspection today at 8:49 am and met with applicant, ZhiYi Mou.

LPA showed the applicant the badge and stated the purpose of this announced inspection. The applicant accompanied with LPA to conduct a Health and Safety Inspection to the Home. The applicant stated the Home operation schedule is from Monday to Friday, 8:30 am to 6:00 pm. LPA inspected the following areas,

The on limit areas are living room, bedroom 1, and bathroom 1. The off limit areas are kitchen, bathroom 2, master bedroom and bedroom 2 which are inaccessible by gates and locked doors. There is no fireplace in the Home. The Home has a fully charged (TYPE: 3A 40 BC ) fire extinguisher in the kitchen; the working smoke detector and carbon monoxide detector are in the kitchen, living room and bedroom. All hazardous and toxic materials are kept in the storage and inaccessible to the children.



The outdoor play area is fenced and free from defects or dangerous conditions. The ground is well covered with resilient artificial grass material. There are no pools, hot tubs, or any other bodies of water. There are plenty age-appropriate toys that appear to be safe and in good condition.

LPA reminded applicant that smoking, baby walkers, and similar items are not allowed in Family ChildCare Homes. The applicant has working telephone.

The Applicant CPR and First Aid certificate is current and will expire Aprt, 22, 2025. LPA reminded the applicant to keep the certificates updated. Applicant completed the Mandated Reporter Training for Child Care Providers that expires on 05/29/2026. Applicant was reminded of Mandated reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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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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: MOU, ZHIYI
FACILITY NUMBER: 434417452
VISIT DATE: 01/31/2025
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Applicant states there are no firearms in the home and there is no one smoke in the Home. Applicant states that a child will be isolated in the ISOLATED AREA if necessary due to illness or communicable disease.

Applicant has a First Aid kit with two touch less thermometers in the home. The Indoor temperature is 54 degrees. LPA shares the regulation 102417, the home shall be kept clean and orderly, with heating and ventilation for safety and comfort. LPA discussed with Applicant the requirements for reporting suspected child abuse, unusual incidents/injuries, and heat related illnesses.

Forms of discipline to be used by applicant are positive influence through talking, reasoning and explain. Applicant understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature.

LPA informed the Applicant that fire/disaster drills must be practiced at least once every 6 months and documented. Applicant provided proof of control of property to the Department prior to today’s inspection and a copy of the property tax bill is on file.

Applicant does not have liability insurance at this time and will issue Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) to all enrolling families until she obtains liability insurance in the future.

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, 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.

Applicant states that she will not administer any medication to the children at this time.

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: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
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: MOU, ZHIYI
FACILITY NUMBER: 434417452
VISIT DATE: 01/31/2025
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LPA reviewed with applicant the LIC 311D, 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.

LPA discussed the safe sleep regulations with applicant, ZhiYi Mou 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.

On this date, 01/30/2025, 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 been 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.

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.

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.


Exit interview conducted and report was reviewed with the Applicant, ZhiYi Mou. LPA advised the applicant that a Small Family Child Care Home license will be approved pending Licensing Program Manager’s review.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC809 (FAS) - (06/04)
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