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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700162
Report Date: 08/31/2022
Date Signed: 08/31/2022 02:19:29 PM

Document Has Been Signed on 08/31/2022 02:19 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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:CHANG, ANNYFACILITY NUMBER:
015700162
ADMINISTRATOR:CHANG, ANNYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 579-2118
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
08/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:ANNY CHANGTIME COMPLETED:
03:30 PM
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Licensing Program Analyst Sidney Cortez, met with licensee ANNY CHANG for an UNNNOUNCED ANNUAL RANDOM INSPECTION. Present for this visit was the licensee ANNY CHANG . The home was toured to conduct a Health and Safety Inspection. The facility currently operates from 8:00AM until 5PM, MONDAY-FRIDAY. The home is single story. The home consists of 3 bedrooms, 2 bathrooms, living room, family room, kitchen, garage and backyard. There is no pool or any type of bodies of water in the home. According to the licensee, and visually confirmed by LPA Cortez, there is no firearm in the house.

The home is neat and clean with heating and ventilation for safety and comfort.



The OFF LIMIT AREAS are the 1 master bedroom, 1 bathroom inside the bedroom, kitchen, and garage.

The ON LIMIT AREAS are the family room, living room, 1 bathroom, 2 bedrooms, dining room, and the left side of the backyard play area where the grass is located. Licensee indicated that while children are playing in the backyard there will be someone to supervise them at all times.

The ISOLATION AREA will be one of the bedrooms (the non master bedroom), located on the left side of the house
There are no pools, hot tubs or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today. Per licensee, there are no firearms in the home. The home has a working smoke detector, carbon monoxide detector, working telephone, and First Aid Kit.The home has a fully charged (3A10BC) fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone.
The licensee CPR and First Aid certificate is current and expires (Nov 2023). The licensee's mandated reporter training is current and expires (June 2024). Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on May 2022. 2 Children files were reviewed, facility roster reviewed and copy obtained. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Sidney Cortez
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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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