343623856-2-22-2021-03-CC-ATIY-BYGUTV-20210222145235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343623856
Report Date: 02/22/2021
Date Signed: 02/22/2021 02:53:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	XIONG, DIA		FACILITY NUMBER:	343623856
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	02/22/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Xiong, Dia		TIME COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA) Alize Tillery contacted Applicant Dia Xiong for the purpose of a scheduled announced pre-licensing tele-inspection. Applicant submitted an application for a small Family Child Care Home license. Due to COVID19 pandemic, a tele- inspection was conducted via Zoom. During today's virtual inspection, applicant’s three children were present. Applicant and all other adults residing in home have obtained a criminal record clearance. Applicant plans to operate Sunday - Saturday from 5:30 AM to 7:30 PM.

A health and safety inspection was conducted inside and out. This is single story facility which includes 4 bedrooms, 2 bathrooms, kitchen/dining room, living room, garage, fenced front yard and fenced backyard. The main area for care will be the living room, dining room and backyard. Applicant will utilize the first bedroom in the hallway for napping purposes. Off-limit areas will include the garage, master bedroom and master bathroom. Applicant understands that children may never enter these off-limit areas.

There is no fireplace in the home. Toxic and hazardous items are inaccessible to children and are stored in locked cabinets. Sharp knives are stored in the kitchen area out of children's reach. All medication is stored in the off-limits master bedroom. A functioning smoke detector, carbon monoxide detector and a full 2A10BC fire extinguisher were observed in the home. LPA observed all required licensing postings along with COVID19 posters.

Report continues on LIC809-C.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Alize Tillery	TELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: XIONG, DIA	FACILITY NUMBER: 343623856
	VISIT DATE: 02/22/2021

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Applicant Dia Xiong has completed the required Preventative Health and Safety course on 10/24/2020. Applicant has a current EMSA certified CPR and First Aid card which expires 10/2022. LPA observed a firearm in the home, stored properly in an off-limits area. There are no bodies of water on the premises. Applicant was encouraged to maintain supervision at all times. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

This facility evaluation report was reviewed and discussed with the Applicant. LIC311D, records, postings, and reporting requirements were discussed. LPA discussed personal rights, criminal record clearances, ratios and capacity, and maintaining buildings and grounds. Applicant was encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. LPA will email this report to Licensee. Acknowledgment of delivery of report constitutes acknowledgement of receipt, in lieu of signature.

As of today February 22, 2021 facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only; or up to 8 children with no more than 2 infants, with 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

SUPERVISOR'S NAME: Maria Mayorga	TELEPHONE: (916) 263-1414
LICENSING EVALUATOR NAME: Alize Tillery	TELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

LIC809 (FAS) - (06/04)

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