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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421543
Report Date: 09/29/2021
Date Signed: 09/29/2021 01:41:31 PM

Document Has Been Signed on 09/29/2021 01:41 PM - It Cannot Be Edited

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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:WU, ZI JUANFACILITY NUMBER:
013421543
ADMINISTRATOR:WU, ZI JUANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 706-8378
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 12DATE:
09/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:56 AM
MET WITH:Zi Juan Wu- LicenseeTIME COMPLETED:
02:00 PM
NARRATIVE
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On 9/29/21 at 10:56am, Licensing Program Analyst (LPA) Briana Plumboy met with licensee Zi Juan Wu for another purpose which resulted in a Case Management inspection due to regulatory violations observed during the inspection. Present for the inspection was 12 children in care (4 infants, 8 preschool) and 2 assistants.

During LPA Plumboy's tour of the facility, LPA Plumboy conducted a record review and observed the 2 assistants present are not associated to the facility, as well as 1 infant was observed buckled inside a car seat drinking his bottle and 2 preschool age children laying in porter cribs on wood slates. The wooden slates were inside the crib in use as a mattress.

LPA Plumboy referred licensee to become familiar with all regulation on safe sleep which can be found in Title 22, Division 12, Chapter 1, Article 6, Section 102425. LPA Plumboy informed licensee these are current regulations and she should be abiding by all regulations.

The attached Type A deficiency regarding criminal record clearance is being cited today. A civil penalty in the amount of $500 is being assessed for each staff who is not currently associated to the facility. The attached Type A deficiency is cited today. Upon receipt, licensee shall post for 30 days and provide copies of this licensing report to parent/guardians of children in care at the facility and to parent/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 Acknowledgement of Receipt of Licensing Reports should be signed by guardians and placed in each child’s file.

This entire report has been read to by LPA Plumboy. The licensee is aware the signature on this report confirm receipt of these documents. LPA asked Licensee Zi Juan Wu if she had any questions pertaining to any aspects including, but not limited to, any part of this report and of the documents given. At this time it was stated there are no further questions at this time. At anytime she can reach out to LPA Plumboy or CCLD.



See 809-D for deficiencies cited today. Appeal rights discussed and provided. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days along with a copy of this entire report. Exit interview conducted.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2021
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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Document Has Been Signed on 09/29/2021 01:41 PM - It Cannot Be Edited


Created By: Briana Plumboy On 09/29/2021 at 12:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: WU, ZI JUAN
FACILITY NUMBER: 013421543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/30/2021
Section Cited
CCR
102370(d)(1)

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Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department.
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Licensee will immediately forward a criminal record transfer request to associate the 2 staff with the facility. Licensee will ensure that prior to working, each staff's fingerprint clearance is associated with the facility.
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This requirement is not met as evidenced by record review.
By 2 staff members fingerprints not being associated, it poses an immediate health and safety risk to children in care.
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TODAY AN IMMEDIATE CIVIL PENALTY OF $1000 IS ASSESSED BECAUSE 2 STAFF CLEARANCES ARE NOT ASSOCIATED TO THIS FACILITY. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Type A
09/30/2021
Section Cited
CCR102423(a)(2)

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Personal Rights. Each child shall be accorded safe, healthful and comfortable accommodations, furnishing and equipment.
This requirement is not met as evidenced by: Based on
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Licensee shall watch video “Personal Rights" at https://ccld.childcarevideos.org. Provide a statement to licensing the video has been viewed, and a summary of what she learned. Submit statement to Licensing by due date of 9/30/21.
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observation when LPA Plumboy entered the child care, there was 1 infant buckeled inside a car seat drinking a bottle, and 2 preschool age children laying on wooden slates in their crib which poses an immediate health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
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:Wynn Norona
LICENSING EVALUATOR NAME:Briana Plumboy
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2021


LIC809 (FAS) - (06/04)
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