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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410267
Report Date: 04/05/2023
Date Signed: 04/05/2023 04:33:21 PM


Document Has Been Signed on 04/05/2023 04:33 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:WANG, XIAOYANFACILITY NUMBER:
434410267
ADMINISTRATOR:WANG, XIAOYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 386-6128
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY:14CENSUS: 11DATE:
04/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:James WoodwardTIME COMPLETED:
04:45 PM
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On Wednesday, April 5, 2023 at 4 pm, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced Required 1 Year Visit. LPA met with the Licensee's Spouse and explained the nature of site visit. Present on this visit were Licensee's Assistant and 11 Children. The home operates from Monday to Friday from 8:30 am to 6:00 pm.

LPA toured the home to conduct a Health and Safety Inspection. The home is a two story home. The home is neat and clean with heating and ventilation for safety and comfort.

The On Limit Areas are the Living Room, Day Care Room, Dining Area, Hallway Bathroom, Day Care Room (for napping), Sun Room and the Backyard. The backyard is completely fenced.
The OFF-LIMIT AREAS are the entire second floor, the kitchen, and the garage which will be inaccessible to children in care by closed and or locked doors and or a fence with visual supervision. There is a gate located at the bottom of the stairs to prevent access to the second story. The designated isolation area for a child who becomes ill while in care is the Dining Area. There are ample age appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs or any other bodies of water present during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.

The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector and working telephone. The fireplace is screened to prevent access by children. Licensee owns the house and has childcare liability insurance with DCI.

Licensee's spouse completed a CPR and 1st Aid Training and certificate will expire on 04/2023.

See 809 C.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2023
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: WANG, XIAOYAN
FACILITY NUMBER: 434410267
VISIT DATE: 04/05/2023
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Continuation.

Facility roster of children was reviewed. Children’s files were reviewed, which included records of receipt for Parents' Rights Notice, Identification and Emergency Information, Consent for Emergency Medical Treatment form, and Immunization. The licensee is in ratio today.

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.

LPA Estoesta discussed American Rescue Plan Act Survey and Child Care and Development Infrastructure Grant Program

There are no deficiencies cited on this visit.

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.

Exit interview conducted and report was reviewed with the licensee's spouse, James Woodward.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel EstoestaTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2