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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415400
Report Date: 04/23/2019
Date Signed: 04/23/2019 09:16:43 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:LEI, XIAOFACILITY NUMBER:
434415400
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
04/23/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Xiao LeiTIME COMPLETED:
09:25 AM
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Licensing Program Analyst (LPA) Oscar Huang met with Licensee, Xiao Lei for an unannounced case management visit to amend a report dated on 04/16/2019. LPA explained the nature of today’s visit to Licensee. LPA also observed one adult assistant and three day care children (two infants & one preschool child) in the home during today's inspection. The assistant's Tdap Vaccine proof records also obtain on site.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2019
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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