343623856-1-13-2022-03-CC-ATIY-CAMRGT-20220113120115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343623856
Report Date: 01/13/2022
Date Signed: 01/13/2022 12:01:25 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:	XIONG, DIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 329-2063
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95838
CAPACITY:	14	CENSUS: 2	DATE:	01/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Dia Xiong		TIME COMPLETED:	12:15 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 January 13, 2022 at 10:45 AM, Licensing Program Analyst (LPA) Alize Tillery met with Licensee Dia Xiong for the purpose of an annual required 1 year inspection. The facility’s days and hours of operation are Monday - Friday from 5:30 AM to 7:30 PM. Present in the home today was Licensee and her two minor children. All individuals subject to criminal background review have obtained a criminal record clearance. Licensee offers transportation services. A health and safety evaluation was conducted in all areas accessible to children. Off limit areas consist of: the master bedroom and bathroom, bedroom #2, bedroom #3 and garage. LPA observed a 2A10BC fire extinguisher, first aid kit and functioning smoke and carbon monoxide detectors. Per licensee, a firearm is stored properly in an off limits area. No children were observed in parked cars. Toxic and hazardous items are inaccessible to children, and safe toys were observed. LPA reviewed children’s files for 3 day care children, files were observed to be complete. Required postings and the children’s roster were observed. Licensee has record of conducting fire drills at least every six months. Per record, last drill was conducted on 11/2/2021. LPA observed COVID19 posters and current guidelines were discussed. LPA observed licensee’s CPR and First Aid card which expires 10/24/2022. Licensee’s and all other adult files were reviewed and were observed to be complete. LPA discussed the requirement of renewing mandated reporter training every 2 years. Licensee’s Mandated Reporter Training is current and expires on 11/29/2023. LPA provided a list of documents that are to be kept in the assistant’s file. Continued on LIC809C…

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize Tillery	TELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: XIONG, DIA	FACILITY NUMBER: 343623856
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(1)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that Licensee has not been documenting sleeping infants every 15 minutes, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/03/2022
	Plan of Correction
1 2 3 4	Licensee will submit proof to LPA Tillery of documentation for sleeping infants, every 15 minutes.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize Tillery	TELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

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: 01/13/2022

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Licensee stated she paid her licensing fees for 2022.

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 submitting 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

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 [facility representative] 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.

A notice of site visit was given and must remain posted for 30 days. Exit interview was conducted and report was reviewed with the Licensee, Dia Xiong.

A deficiency is cited on the following LIC809D. Appeal Rights were provided.

SUPERVISOR'S NAME: Seychelle De Luca	TELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Alize Tillery	TELEPHONE: (916) 216-7798
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2022

LIC809 (FAS) - (06/04)

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