Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016331
Report Date: 08/01/2017
Date Signed 08/01/2017 12:37:30 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: 6DATE:
08/01/2017
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Feng Si CaiTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Case Management inspection conducted by Licensing Program Analyst (LPA) Jennifer Hua. LPA met with licensee, Feng Si Cai. Licensee's dad Lizhan Cai also present during this visit. The purpose of this inspection is discussed the incident that occurred on 6/27/17 and was reported on 6/29/17. A child sustained an injury to the finger when another child closed the door onto the child's finger. Per licensee, she was cooking in the nearby kitchen and was not aware that incident occurred until child cried.

Based information received, deficiencies cited on attached 809D.

An exit interview conducted, copy of report given. Appeals rights provided and explained.

Upon receipt of this report documenting a substantiated complaint allegation and a Type A deficiency, the licensee shall do the following:
1. Post the Notice of Site visit and any licensing report documenting a Type “A” deficiency.
2. The report and the Notice of Site visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty.
3. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year).
4. The Acknowledgement form (LIC 9224) must be maintained in each child’s file immediately upon receipt from parent. A copy of the parent Acknowledgement of Receipt of Licensing Reports Form was provided during this visit.
SUPERVISOR'S NAME: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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, 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: 08/01/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/02/2017
Section Cited
102416.2(a(b)3B
1
2
3
4
5
6
7
Reporting Requirements. The licensee shall report the following information to the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). Incident occured on 6/27/17 and licensee reported it on 6/29/17.
1
2
3
4
5
6
7
Per licensee, she understands reporting requirement but forgot to report it the next day, and realized it 2 days later.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2017
LIC809 (FAS) - (06/04)
Page: 3 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, 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: 08/01/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2017
Section Cited
102417(a)
1
2
3
4
5
6
7
Operation of a Family Child Care Home. The licensee shall be present in the home and shall ensure that children in care are supervised at all times. A child finger was infured when another child closed the door on the child's finger. Per licensee, she was cooking and was not aware until the child cried.
1
2
3
4
5
6
7
Per licensee, children are supervised closely, talked to children to be more careful. Will install device to prevent door from closing all the way. Will submit photo of correction.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Claudia GuangorenaTELEPHONE: (323) 981-3417
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3