Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420448
Report Date: 11/14/2018
Date Signed 11/15/2018 01:56:29 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: 14DATE:
11/14/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Zhao Xian YangTIME COMPLETED:
04:15 PM
NARRATIVE
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An unannounced Annual/Random site visit was conducted b y LPA Susan Neeson. Met with Zhao Xian Yang, Assistant. Licensee Zhi He arrived at 2:45. There are 3 adults fingerprint clear and associated with the facility. She resides here with her adult son. Her assistant is present with 14 children. 2 are school age and the rest 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 one 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 in the kitchen. The smoke alarm works and there is a carbon monoxide detector The family has two 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. Children's records are being maintained. Roster is current. Fire/earthquake drills are being done and documented. Required forms are posted.

This facility plans to provide Incidental Medical Services – IMS. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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)/ (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

SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2018
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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: HE, ZHI
FACILITY NUMBER: 013420448
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2018
Section Cited
CCR
102416.5a
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`Staffing Ratio and Capacity. The capacity specified on the license shall be the maximum number of children for whom care can be provided. This regulation was not met as evidenced by 1 staff person and 14 children from 2:10-2:45 PM.
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Correct ratio and capacity will be met at all times. Corrected during visit when Zhi He returned at 2:45.
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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: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2018
LIC809 (FAS) - (06/04)
Page: 2 of 3
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: HE, ZHI
FACILITY NUMBER: 013420448
VISIT DATE: 11/14/2018
NARRATIVE
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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

Requested copy of LIC 9040 for the file.

Deficiency is cited on LIC 809 D. Appeal Rights were discussed. An exit interview was given.


REPORT WAS NOT ISSUED DURING VISIT DUE TO EQUIPMENT MALFUNCTION.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2018
LIC809 (FAS) - (06/04)
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