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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700339
Report Date: 06/16/2022
Date Signed: 06/16/2022 01:52:12 PM

Document Has Been Signed on 06/16/2022 01:52 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:FAN, SITINGFACILITY NUMBER:
435700339
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Siting "Gracie" FanTIME COMPLETED:
02:15 PM
NARRATIVE
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On 06/16/2022 at 12:00pm Licensing Program Analyst (LPA) Christina Uribe, met with licensee Siting "Gracie" Fan for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 4 daycare children and the licensee is within ratio today. Upon arrival LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 8:30am-5:30pm.

The home is a single story home with 3 bedrooms, 1 bathroom, living room, kitchen, dining area, detached garage and back yard. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort. All on/off-limit areas are not consistent with the facility's pre-licensing reports and a new Facility Sketch (LIC 999) will need to be emailed to LPA Uribe.

The OFF-LIMIT AREAS are Bedroom #1, the kitchen, and the detached garage and are inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS are the living room, dining area, bedroom #2, bedroom #3, bathroom and the backyard.

The facility’s outdoor play space is located in the backyard of the home. The toys, equipment, and fence are all in safe condition free from hazards which could pose a risk to children in care. There is ample shade available and gates are locked at all times while children are in the yard. Licensee has a chicken coop with three chickens located in the far end of the backyard.

Page 1 of 3 ***Continued of LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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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Document Has Been Signed on 06/16/2022 01:52 PM - It Cannot Be Edited


Created By: Christina Uribe On 06/16/2022 at 01:01 PM
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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: FAN, SITING
FACILITY NUMBER: 435700339

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the doors to the bedrooms where the infants are napping were closed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/15/2022
Plan of Correction
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Licensee will review the safe sleep regulations on the CCLD website on the "Safe Sleep in Child Care" page. Licensee will review these regulations and create a list of ways that she will implement the safe sleep regulations in her family child care home and email this to LPA Uribe no later than the due date of 07/15/2022.
Email: Christina.Uribe@dss,ca,gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022


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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: FAN, SITING
FACILITY NUMBER: 435700339
VISIT DATE: 06/16/2022
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All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide, telephone and fully stocked first aid kit. There are no pools, hot tubs or any other bodies of water present outdoors at the time of the inspection. The licensee does have a fish tank in the living room. Per licensee, there are no firearms on the premises.

The licensee completed the Health and Safety training, CPR/First Aid certification expires on 06/20/23. The licensee is in compliance with the immunization laws and has completed the mandated reporter training on 09/12/21. The licensee conducts fire and disaster drills twice a year and the last conducted drill was on 02/01/2022. Drills are not documented. All required forms are posted and visible for public review.

At 12:30pm LPA Uribe reviewed 7 children’s files and personnel records. Sleep Charts for sleeping infants were not available as the licensee was not aware it was needed for children over the age of 12 months. There is a facility roster available for review which is in need of being updated. The facility does have liability insurance which is valid through 04/08/2023. Staff interview also conducted and documented.



Incidental Medical Services (IMS) policy was discussed and the facility does not have any children with the need for medication to be kept at the facility at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department

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 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-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.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: FAN, SITING
FACILITY NUMBER: 435700339
VISIT DATE: 06/16/2022
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Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

Application for Capacity Increase: All documents have been received for the increase of capacity application. The fire clearance for a capacity of 14 children was received from the Los Altos Fire Department on 05/26/22. The licensee was reminded to abide by the conditions of the fire clearance. The licensee is reminded that prior to accepting more than 8 children into care, an assistant must be hired, fingerprint cleared, and associated to the facility. The licensee was reminded that the assistant must be present at all times when there is more than 8 children in attendance. Whenever the assistant is not present, the licensee will comply with the capacity requirements for a small family child care home.

The home is recommended for an increase of capacity. There is one violation and four technical violations being issued today: Please see attached deficiency pages and advisory notes.


    Type B Violation: LPA Uribe observed napping infants in two separate bedrooms which had both doors closed which is not in compliance with the safe sleep regulations.

    Technical Violation: Licensee already performs emergency drills but will need to begin documenting them as well.

    Technical Violation: A new facility sketch (LIC 999) will need to be emailed to LPA Uribe at [email protected] which reflects that two of three bedrooms are on limits to children in ca

    Technical Violation: One child needs to have an updated copy of their medical immunization record from the physician.

    Technical Violation: 15-minute checks must be performed and documented for all infants, children of ages 24 months or younger, while sleeping.


A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Siting "Gracie" Fan.

Page 3 of 3 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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