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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419195
Report Date: 03/07/2022
Date Signed: 03/07/2022 02:09:27 PM


Document Has Been Signed on 03/07/2022 02:09 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:LU, XIAOLINGFACILITY NUMBER:
013419195
ADMINISTRATOR:LU, XIAOLINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 673-6588
CITY:FREMONTSTATE: CAZIP CODE:
94539
CAPACITY:14CENSUS: 11DATE:
03/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Xiaoling LuTIME COMPLETED:
02:35 PM
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On 3/7/2022, Licensing Program Analyst (LPA) Melanie Otsuji, met with licensee Xiaoling Lu for an UNANNOUNCED 1 YEAR REQUIRED INSPECTION. Also present with the Licensee were 2 fingerprint cleared assistants, a fingerprint cleared spouse and 11 children (4 infants, 7 preschoolers). The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday through Friday from 8:30am until 6:30pm.

Physical Plant: Storage areas for poisons are locked. Detergents, cleaning compounds, medications, and other items which could pose a danger to children are stored where they are inaccessible to the children in care. Fire extinguishers and smoke detectors meet State Fire Marshall standards. The home is kept clean and orderly, with heating and ventilation for safety and comfort. The home has working telephone service. Care and Supervision: Outdoor play area is fenced and supervised by the licensee. On this date, the facility is within the capacity specified on the license Records Review: The licensee has completed training on preventive health practices including pediatric CPR and first aid. The home has a fully charged fire extinguisher, working smoke detector, and working carbon monoxide detector. Per licensee, there are no firearms in the home. Children files were reviewed, facility roster requested and will be emailed. All REQUIRED forms are posted and visible for public review.

Incidental Medical Services (IMS) policy was discussed. 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) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LU, XIAOLING
FACILITY NUMBER: 013419195
VISIT DATE: 03/07/2022
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

No deficiencies noted on today's date. A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Xiaoling Lu.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Melanie OtsujiTELEPHONE: (510) 341-5559
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2022
LIC809 (FAS) - (06/04)
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