434411367-11-7-2019-07-CC-DMAC-BHPQS4-20191107112456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434411367
Report Date: 11/07/2019
Date Signed: 11/07/2019 11:25:02 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	XUE, SHAO		FACILITY NUMBER:	434411367
ADMINISTRATOR:	XUE, SHAO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 238-3502
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	14	CENSUS: 11	DATE:	11/07/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Xue, Shao		TIME COMPLETED:	11:30 AM

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	Licensing Program Analyst (LPA) Dung Mac met with Shao Xue, Licensee, for an unannounced annual inspection. Present were Licensee, Licensee's spouse/assistant, Licensee's mother/assistant, Licensee's daughter age 4, and ten day care children, of whom were 2 infants and 8 preschoolers. Days and hours of operation are: Monday-Friday 7:30am-5:30pm. LPA toured the home both inside and out. Off-limit areas are all bedroom and garage. The backyard is fenced. The storage shed in the backyard is locked and off limit. LPA did not observe any bodies of water. Licensee states that there are no firearms in the home. Detergents, cleaning products, medications, hazardous and other toxic materials are inaccessible to children. LPA observed a fully charged fire extinguisher sized 3A40BC. Smoke and Carbon Monoxide detectors were tested and proved to be functioning. The home is clean, orderly, and safe for the day care children. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed that the wall heater is screened to prevent access by children. Licensee stated that she does not transport children. LPA reviewed the Child Care Facility Roster. Ten children's files were reviewed and all are complete. The last fire/disaster drill was conducted on 10/22//19. Licensee's Pediatric CPR & First Aid certification expires on 2/10/21. Licensee, spouse, and Licensee's mother maintain records of immunization. Licensee's Mandated Report training expires 1/25/20. LPA reminded Licensee that the Mandated Reporter Training needs to be renewed every two years. REPORT CONTINUED ON PAGE # 2

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: XUE, SHAO	FACILITY NUMBER: 434411367
	VISIT DATE: 11/07/2019

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

A review of records on 11/07/19 shows that all staff and other adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Adults who reside in the home are Licensee, Licensee's spouse, and Licensee's mother. They have Clearances for Tuberculosis, and Criminal Background and Child Abuse Index Checks. LPA reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license, and who come in contact with or provide care and supervision to the children.

Licensee stated she does not have any children in care who requires administration of medication. The facility is not providing Incidental Medical Services. IMS was discussed. The following US Department of Justice resource was provided: http://www.ada.gov/childqanda.htm.

LPA provided a copy of the “Lead Poisoning Facts Information Flyer” and Safe Sleep Information to Licensee.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing updates and regulations. Licensee was reminded that Mandated Reporter for all staff is required. The Mandated Reporter Training website is http://mandatedreporterca.com.

No deficiency was cited today. An exit interview was conducted. Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019

LIC809 (FAS) - (06/04)

Page: 2 of 2