013420759-6-28-2022-52-CC-KPHN-CFTSP3-20220628140227

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013420759
Report Date: 06/28/2022
Date Signed: 06/28/2022 02:02:38 PM

Document Has Been Signed on 06/28/2022 02:02 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:	XIAO, HONG		FACILITY NUMBER:	013420759
ADMINISTRATOR:	XIAO, HONG & WANG, LIYAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 203-3525
CITY:	FREMONT	STATE: CA	ZIP CODE:	94538
CAPACITY:	14	CENSUS: 10	DATE:	06/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Hong Xiao		TIME COMPLETED:	02:10 PM

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	On 06/28/2022 approximately at 11:20AM Licensing Program Analyst (LPA) Kelly Phan arrived at for an unannounced required inspection, and met with Licensee Hong Xiao. Present for this inspection was the licensee, 4 infants, 6 preschoolers along with a fingerprinted and associated helper. Also residing in the home is the licensee's fingerprinted and associated roommate. Per licensee, she has three children of her own between the ages of 11, 16, and 22 years old, but does not reside in the home. The home was toured with the licensee to conduct a health and safety inspection. Hours of operation for day care are Monday through Friday, 8:00am to 6:30pm. ON LIMITS: bathroom #1, fenced backyard, living room (isolation area), bedroom #1 (across from bathroom #1) and day care play room OFF LIMITS: garage, kitchen, left and right side yard, bedroom #2 (licensee's master bedroom), bathroom #2 (master bathroom), and bedroom #3 (roommate's room); front yard. Off limit areas are inaccessible by closed and/or locked doors, and visual supervision. The home is single story, which is neat and clean, with heating and ventilation for safety and comfort. There were ample age appropriate toys that were observed to be safe and in good condition. At 11:40AM, LPA toured the ON limit areas with licensee; LPA observed the bathroom and found that there were some shaving gel and nail polish in the bottom drawer; LPA suggests to licensee to have a child safety lock on it to prevent access to potential hazardous items. Licensee states she would add a lock or use the step stool to block it. LPA also observed a child sleeping mobile attached to one of the sleeping cribs; Licensee immediately removed it. LPA observed the changing table area and informed licensee to keep lotions and diaper creams away from children; Licensee immediately removed it to a cabinet nearby the changing table. There were a fully charged 3A40BC fire extinguisher located in the garage, working carbon monoxide, smoke detectors, and telephone. The home has a fireplace but is blocked off by a glass mirror. Per licensee, there are no firearms or pets or any bodies of water in the home. SEE LIC 809 C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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: 06/28/2022

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

LPA observed that licensee conducts and documents fire drill log indicates a drill was conducted 02/15/22. All required licensing documents are posted and visible for public review. At 12:18pm, 6 children's files were reviewed and found that there were some forms missing signatures for LIC 700 and LIC 627; LPA observed that licensee has day care insurance from Markel Insurance Company valid until 07/23/2022 that meets the liability requirements. LPA also verified with licensee that she does not have a physical file for her helper to review; LPA suggests licensee to obtain signed forms and to complete mandated reporter training from her helper by 07/08/2022. The facility roster was reviewed, and a copy obtained. The licensee is in ratio today. Licensee has proof of the required immunization. The licensee have required mandated reporter training that is completed as of 09/09/2021. CPR and First Aid training are also updated as of 01/01/2024 for licensee and her fingerprinted and associated roommate who sometimes assist her while she goes out for errands. LPA also reminded licensee that children who are 2 years old and up will be required to wear masks indoors, those who have medical exemptions to referred to our CDSS website for additional resources.

There were no deficiencies were cited for today's inspection

Appeal rights and a notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00. Exit interview conducted and report was reviewed with licensee Hong Xiao

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. SEE LIC 809 C

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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: 06/28/2022

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

Incidental Medical Services (IMS) policy was discussed. This facility does not provides IMS to children in care. 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.”

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.

Licensee was reminded that California Law requires licensed Child Care Centers 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 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the Facility Representative that all forms can be downloaded at www.ccld.ca.gov and encouraged the Facility Representative to email childcareadvocatesprogram@dss.ca.gov to be included in the Child Care Quarterly Updates distribution list. Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

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.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 622-2631
LICENSING EVALUATOR NAME: Kelly Phan	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3