Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420448
Report Date: 01/05/2017
Date Signed 01/05/2017 04:17:38 PM

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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:HE, ZHIFACILITY NUMBER:
013420448
ADMINISTRATOR:HE, ZHIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 559-3687
CITY:ALBANYSTATE: CAZIP CODE:
94706
CAPACITY:14CENSUS: 12DATE:
01/05/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Zhi HiTIME COMPLETED:
04:30 PM
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(2) An unannounced Annual/Random site visit was conducted b y LPA Susan Neeson. Met with Zhi He, Licensee. There are 4 adults fingerprint clear and associated with the facility. CPR and First Aid are current for Zhi He, her son and assistant. She resides here with her adult son. Her assistant is present today. There are 12 children present, 7 of the children are school age and five are preschoolers.

A health and safety tour of the home was done. The home has three bedrooms and one and a half baths. One bedroom is off-limits. Day care is done in two of the bedrooms, used primarily for napping, living/dining area. Children use the 1/2 bath off the kitchen. It contains no hazards. There is also a play area in the converted garage. The yard contains no hazards and is fully fenced. The fire extinguisher 2A 10 BC is on a wall in the kitchen. The smoke alarm works a carbon monoxide detector T The family has three pets, a bunny in a cage in the garage and two medium sized dogs. The dogs stay in the son's room. There is no body of water. There are sufficient toys and equipment for the children in care. The floor heater has a secure barricade. There is no fireplace. All electrical outlets are covered. Cleaning products, sharp knives and medicine are all inaccessible to children. There are sufficient mats for napping. Zhi He states that she has day care insurance. Children's records are being maintained. Roster is current. Fire/earthquake drills are being done and documented. Required forms are posted.

Incidental Medical Services were discussed. Zhi He states that there are no children presently enrolled who are in need of IMS. If children in the future require IMS a procedure will be submitted for the file.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov and for day care updates visit www.myccl.gov

Zhi He states that there are no guns or firearms in the home.

No deficiencies are observed. An exit interview was given.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2017
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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