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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623856
Report Date: 07/28/2021
Date Signed: 07/28/2021 09:59:18 AM

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, DIAFACILITY NUMBER:
343623856
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 7DATE:
07/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dia XiongTIME COMPLETED:
10:15 AM
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On Wednesday, July 28, 2021, at 9:15 AM, Licensing Program Analysts (LPAs) Alize Tillery and Gagan Singh conducted a Case Management inspection for the purpose of increasing the maximum capacity from 8 to 14 children. During the inspection there were 7 children supervised by Licensee. The Fire Safety Inspection Clearance has not been received. With the help of the Licensee, a health and safety inspection of all areas accessible to children was conducted. The Off-limits areas includes the master bedroom and master bathroom and the garage. Licensee acknowledged that children may never enter these off-limit areas. Current CPR/First Aid certificate (expires: 10/2022), posted License, Parent's Rights, Emergency Disaster Plan, and Fire Drill Log are all being maintained by the Licensee. Hazardous items were stored inaccessible to children in care and locks were observed on cabinets. Licensee has three dogs in the home. Per Licensee, a firearm in the home is stored properly in an off-limits area.. Fire extinguisher (2A10BC), carbon monoxide and smoke detector meet regulation. The outdoor area used by children at this time is fenced and age appropriate toys were observed. The Licensee understands that 100% supervision is required in any unfenced areas. There are no bodies of water on the premises. Licensee understands that prior to making alterations or additions to the home or grounds, the licensee shall notify the Department of the proposed changes. During the inspection, LPAs discussed ratio and capacity requirements and requested Licensee submit an updated Emergency Disaster Plan.

As of today, Capacity Increase is pending approval:
- Approved Fire Clearance

In the areas that were evaluated, no deficiencies were observed at the time of the inspection. This report and a Notice of Site Visit was provided to Licensee. Licensee acknowledges the Notice of Site Visit must be posted for 30 days.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize TilleryTELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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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