Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016331
Report Date: 11/03/2015
Date Signed 11/03/2015 12:42:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:CAI FAMILY CHILD CAREFACILITY NUMBER:
198016331
ADMINISTRATOR:CAI, FENG SIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 587-2315
CITY:BALDWIN PARKSTATE: CAZIP CODE:
91706
CAPACITY:14CENSUS: 4DATE:
11/03/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Feng Si CaiTIME COMPLETED:
12:50 PM
NARRATIVE
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This is an annual random visit conducted today by Jennifer Hua, LPA. LPA met with licensee. Licensee who guided analyst on a tour of the facility. All areas identified on the facility sketch were inspected. This is a single story home. Family members residing at facility are 4 adults and 2 children. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. The home was inspected as follows: living room, first bedroom, hall bathroom, fenced backyard. Per Licensee, there are no weapons, firearms in the facility at this time, no swimming pool, spa or other bodies of water observed on the premises. There are age appropriate toys and equipment on the premises. The required fire extinguisher (2A 10BC) and smoke/carbon monoxide detector are in operable condition. Pediatric CPR/First Aid certificate expires on 4/6/2016. The following were discussed: No smoking, No Infant walkers, No Johnny jumpers, No Baby bouncers No exersaucers and any other item that falls into that category permitted in the facility. Earthquake & fire disaster drill, posting requirements, children records requirements, injury/ death reporting, criminal records, child abuse clearance and criminal records transfer requirements. The Departmental web site address to order forms is www.ccld.ca.gov. Drills conducted on 9/30/15. Incidental medical services discussed and explained. Per licensee, service is not provided.

A review of staff records on today indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Non fingerprinted adult in the home may be fined up to $500.00 per person.

The requirement of posting the Notice of Site Visit By a Child Care Licensing Office Representative and the civil penalty of not posting the Notice were explained to licensee.

Deficiencies are cited on attached 809D.

Exit interview conducted with licensee, copy of report given.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2015
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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CAI FAMILY CHILD CARE
FACILITY NUMBER: 198016331
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/03/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2015
Section Cited
102417(g)(1)
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Operation of a Family Child Care Home. Fire extinguisher and smoke detector shall meet state fire marshal standard. LPA observed fire extinguisher is fully charged but has not been serviced.
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Per licensee, will service it and submit copy of service tag.
Type B
11/09/2015
Section Cited
102418(g)(1)
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Immunizations. LPA observed 1 file lack immunization record.
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Per licensee, will correct and submit copy to Licensing
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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: Christina GabelmanTELEPHONE: (323) 981-3395
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2015
LIC809 (FAS) - (06/04)
Page: 2 of 2