Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016331
Report Date: 03/02/2017
Date Signed 03/02/2017 09:28:09 AM

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: 2DATE:
03/02/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Feng Si CaiTIME COMPLETED:
09:40 AM
NARRATIVE
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Annual random inspection conducted by LPA Jennifer Hua. LPA Met with licensee, who guided the analyst on a tour of the facility. The facility is a single dwelling, with 3 bedrooms and 2 bathrooms. Licensees speak primarily Cantonese and Mandarin and some English. This visit was conducted in Cantonese. Per licensee, people live in the home are 4 adults and 2 minors. Licensee's parents were also present during visit.

Areas used by children were inspected as follows: Kitchen area, living room, dinning area, bathroom and 1 bedroom use for napping and fenced backyard.

Per licensee, there are no weapons, firearms, *swimming pool or spa on the premises. The backyard is adequately fenced.
There are age appropriate toys and equipment on the premises. The smoke/carbon monoxide detectors and fire extinguisher (2A 10BC) are in operable condition. Fire extinguisher was purchased on 10/11/16.
Areas off limits include: 2 bedrooms and one bathroom and back room behind kitchen and front yard.
-CPR expires 4/3/2018 and First Aid expires 4/3/2018.
-Child Care Roster, Disaster Plan, and Children's Records were reviewed.
-Children records and required licensing forms were discussed as well as mandated child abuse reporting and criminal records clearance (finger prints and child abuse clearance) requirement.
The following was discussed: Individuals who are 18 years of age or older living/working in the home must be finger print cleared prior to licensure. Individuals within one month of their 18th birthday must be fingerprinted immediately. The existing, immediate $100 per individual Civil Penalty has been increased to an immediate $100 per day Civil Penalty, for a maximum of five days for the first violation and a maximum of 30 days for subsequent violations. If an individual has a clearance with the Department a criminal record clearance may be transferred. LIC 9182 Criminal Background Clearance Transfer Request may be used
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2017
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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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: 03/02/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2017
Section Cited
102418(g)(1)
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Immunizations. The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. LPA observed 1file lack record and 1 needs updates.
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Per licensee, will correct and submit copies to Licensing
Type B
04/03/2017
Section Cited
H&S1596.7995(c)
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Immunization Requirements. Effective 9/1/16, all adults who provide care and supervision are required to obtain immunizations for Pertussis, Measles and Influenza. Records not available for licensee and her parents who also help with the day care.
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Per licensee, will correct and submit copies 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) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2017
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
VISIT DATE: 03/02/2017
NARRATIVE
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Rooms that are off-limits need to be made inaccessible during operating hours. No smoking, No infant walkers, Johnny jumpers, exersaucers, bouncers and any other item that falls into that category, earthquake – fire, disaster drills and safety, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal records, child abuse clearance and criminal records transfer requirements, SIDS, Never Shake A Baby, A Child Care Provider's Guide to Safe Sleep was provided to licensee. Drills were conducted on 11/22/16. .

Incidental Medical Services (IMS) policy was discussed. 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. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0388 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm


· Dog(s) and or pets should be isolated from children in care.
· It is recommended that a First Aid kit be available on premises.
Outdoor supervision required at all times. If outdoor area not adequately fenced provider must be with children at all times when outdoors.

Deficiencies cited on attached 809D..


Exit interview was conducted with licensee. Appeal Rights procedures explained and provided.
Site visit notice posted. And Licensee advised to keep notice posted for 30 days.
Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l
INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 854-6738
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3