Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016331
Report Date: 05/23/2018
Date Signed 05/23/2018 09:20:37 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:
05/23/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:19 AM
MET WITH:Feng Si CaiTIME COMPLETED:
09:25 AM
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
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 story 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 3 adults and 2 minors. Licensee's father also present during visit.

Areas used by children were inspected as follows: Kitchen area(eating only), living room, 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 serviced on 11/13/17.
Areas off limits include: 2 bedrooms and one bathroom, kitchen and back room behind kitchen and front yard.
-Licensee is current in Pediatric CPR/First Aid. Certificates will expires 3/10/2020.
-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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2018
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
VISIT DATE: 05/23/2018
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
26
27
28
29
30
31
32
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 3/23/18. Affidavit for Liability insurance form in children's files. Licensee was informed to complete the Mandated Reporter Training on department website at http://www.mandatedreporterca.com/, if the training is available in her language.

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 Per licensee, IMS is not provided.


· 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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2018
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, 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: 05/23/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/29/2018
Section Cited
CCR
102418(g)(1)
1
2
3
4
5
6
7
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.
1
2
3
4
5
6
7
Per licensee, will correct and submit copies to Licensing.
8
9
10
11
12
13
14
This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home. LPA observed 2 files need updates. This is a potential health and safety risk to chidlren in care.
8
9
10
11
12
13
14
Type B
05/29/2018
Section Cited
CCR
102419(d)
1
2
3
4
5
6
7
Admissionn Procedures and Parental and Authorized Representative Rights. At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parents’ Rights, LIC 995A (8/06), the Caregiver Background Check Process Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
1
2
3
4
5
6
7
Per licnesee, will correct and submit copy to Licensing.
8
9
10
11
12
13
14
LPA observed form not completed in 1 file. This is a potential risk to the health and safety of children.
8
9
10
11
12
13
14
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: Katherine HarewoodTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2018
LIC809 (FAS) - (06/04)
Page: 3 of 3