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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435700339
Report Date: 04/26/2022
Date Signed: 04/26/2022 05:19:03 PM

Document Has Been Signed on 04/26/2022 05:19 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:SITING, FANFACILITY NUMBER:
435700339
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
04/26/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Siting FanTIME COMPLETED:
05:15 PM
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On 04/26/2022 at 4:00pm, Licensing Program Analyst (LPA) Christina Uribe, Licensing Program Manager (LPM) Chandra Charles, and Regional Manager (RO) Anika Evans conducted an informal meeting at the Community Care Licensing, Child Care Program, Oakland Regional Office and met with licensee Siting "Gracie" Fan. Also present during the meeting is adult resident of licensee's facility, Valeria Androsenko.

The purpose of today's meeting is to discuss the relationship that Androsenko has with the facility and what role her company Square Care has in it's functionality. Androsenko is assigned to the facility as an adult resident in the home as indicated by the application however, Androsenko is also assigned as the adult resident of other family child care homes under different facility numbers. Additionally, the facility has submitted an application for a capacity increase. Facility has been licensed since 07/07/2021 and Siting "Gracie" Fan has been the licensee since 09/29/2021. Fan has 1 year, 9 months experience as a teacher at a licensed child care facility. Prior to today's meeting, LPA Uribe requesting licensee to bring the following documents to complete the application: 1) Copy of current lease/rental agreement of property; 2) Property Owner/Landlord Notification (LIC 9151) form; 3) Property Owner Consent (LIC 9149). LPA Uribe was able to obtain the current lease agreement Licensee was informed by LPA Uribe that the Fire Safety Inspection Request form has been mailed to the Santa Clara County Fire Department (SCCFD) and is waiting to hear from them of confirmation of this. The Department cannot move forward with the increase of capacity request until after the SCCFD has conducted their inspection and LPA Uribe has received the report. LPA Uribe also obtained a current phone number and email address for the facility. Licensee is also advised that all advertisements for the facility must include the facility number and that an assistant is required to be hired prior to serving a capacity of a large family child care home. During today's meeting, LPM Charles requested that Fan resubmit a new application and remove Androsenko as a claimed resident of the home.

Report was reviewed with and copy was given to Fan and Androsenko.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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