434415400-4-21-2022-07-CC-YHUG-CDPU2U-20220421151231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415400
Report Date: 04/21/2022
Date Signed: 04/21/2022 03:12:58 PM

Document Has Been Signed on 04/21/2022 03:12 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	LEI, XIAO		FACILITY NUMBER:	434415400
ADMINISTRATOR:	XIAO LEI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 710-4271
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	14	CENSUS: 6	DATE:	04/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Xiao Lei		TIME COMPLETED:	03:30 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	Licensing Program Analyst (LPA) Oscar Huang met with Licensee, Xiao Lei for an unannounced annual inspection. LPA explained the nature of today’s inspection to Licensee. Present were licensee, a helper, and 3 preschoolers & 3 infants in the home during today's inspection. Days and hours of operation are Monday to Friday, 8:30am to 6:00pm. The adults that reside in the home is licensee, her husband, and her adult daughter. A review of staff records on 04/20/2022 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee, Han Li 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 conducted CARE Tools for this annual inspection, which include Physical Plant, Care and Supervision, Facility Administration, Records, Staffing Ratio and Capacity, Personnel Rights for compliance with all licensing statutes, regulations, and interim licensing Standards, and results were documented on the tool. LPA observed licensee and the helper have current CPR and First Aid certification expiring 10/2023. LPA observed a current roster of the children and a fire and disaster drills log which is to be done at least once every six months. The last drills were conducted on 12/10/2021. LPA reviewed all 6 children files. Immunization records are maintained and up-to-date, and updated in form PM 286. LPA observed Notification of Parents’ Rights is in each child’s file. LPA did not observe 15 minutes sleeping check logs.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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 3

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: LEI, XIAO	FACILITY NUMBER: 434415400
	VISIT DATE: 04/21/2022

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

Supervision of children was discussed with Licensee, and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options. Licensee states that she does not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time.

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 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. 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 submitted 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: https://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/inspection-process.

A deficiency was cited. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Xiao Lei

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/21/2022 03:12 PM - It Cannot Be Edited

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: LEI, XIAO	FACILITY NUMBER: 434415400
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/09/2022
	Plan of Correction
1 2 3 4	Licensee agreed to submit infant sleeping 15 min. check logs to the office prior to the POC due date.

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: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3