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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420759
Report Date: 08/27/2021
Date Signed: 08/27/2021 12:26:13 PM

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:XIAO, HONGFACILITY NUMBER:
013420759
ADMINISTRATOR:XIAO, HONG & WANG, LIYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 203-3525
CITY:FREMONTSTATE: CAZIP CODE:
94538
CAPACITY:14CENSUS: 6DATE:
08/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Hong XiaoTIME COMPLETED:
12:35 PM
NARRATIVE
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On August 27, 2021 at 10:35 AM., Licensing Program Analyst (LPA) Elimika Woods conducted an unannounced Annual Required Inspection and met with licensee, Hong Xiao. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during the inspection were six (6) children, five (5) preschoolers and one (1) infant. LPA toured the home to conduct a health and safety inspection. The facility plans to operate between the hours of 8:30 AM-6:30 PM, Monday -Friday

On-limit-areas are the: Family room, dining room, day care room next to dining room, backyard, bathroom, bedroom across from the bathroom

Off-limit-areas are the: Kitchen, garage, two bedroom located in the hallway, side-yard, shed in the backyard

This single family home ,which is neat and clean with heating and ventilation for safety and comfort. The off-limits are will be made inaccessible by closed and/or locked doors and visual supervision.

The Isolation area will be a section of the family room, away from other children in care. The outdoor play area is the fully fenced backyard and LPA observed that it is free from defects or dangerous conditions. There is a locked shed located inside the back yard and is off limits to children in care.

See 809-Continuation
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: XIAO, HONG
FACILITY NUMBER: 013420759
VISIT DATE: 08/27/2021
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LPA informed the licensee that all forms can be downloaded at www.ccld.ca.gov and encouraged the licensee to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. The licensee was also reminded that Mandated Reporter Training is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility.

California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail.

Roster of the children must be properly maintained and fire/disaster drill every six months must be documented. The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing.

Incidental Medical Services (IMS) policy was discussed. Per licensee, no IMS is being provided at this time. The licensee was reminded that when any changes to the IMS plan is made, an updated 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.”

There are no deficiencies cited. This report shall remain on file for 3 years. Exit interview was conducted with the licensee. A Notice of Site visit was posted at the time of inspection and must remain posted for 30 days.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: XIAO, HONG
FACILITY NUMBER: 013420759
VISIT DATE: 08/27/2021
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There are ample age appropriate toys that appear to be safe and in good condition. The backyard has a large wooden play structure on the right side, which is anchored to the ground and has cushioning to absorb falls. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection.

The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, first aid kit and telephone. There's a fireplace in the living that is blocked to prevent access by children. Per licensee, there are no firearms in the home. The licensee is in compliance with the immunization laws which pertains to all childcare providers. Licensee's CPR and First Aid certificate is current and expires 12/2021. All required forms are posted and visible for public review.

At 10:45 AM LPA requested and reviewed the file of file (5) children in care. The facility roster was reviewed, and copies was obtain. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 08/27/2021. The licensee is in ratio today. The licensee was provided information regarding effects of Lead Exposure and testing requirements (Assembly Bill 2370).

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of her responsibility as mandated reporter.

See Continuation

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Elimika WoodsTELEPHONE: (510) 622-2550
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021
LIC809 (FAS) - (06/04)
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