434415400-4-9-2024-07-CC-YHUG-D46U9J-20240409152315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434415400
Report Date: 04/09/2024
Date Signed: 04/09/2024 03:23:23 PM

Document Has Been Signed on 04/09/2024 03:23 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
SAN JOSE-DAY CARE, 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: 8	DATE:	04/09/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Lei Xiao		TIME COMPLETED:	03:40 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, 4 preschoolers and 4 infants 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 are licensee, her husband, and her adult daughter. A review of staff records on 04/09/2024 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 was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days 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 has current CPR and First Aid certifications which are expiring 3/2026. 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 12/10/2023. LPA reviewed all 8 children files. Not all immunization records are maintained and up-to-date. Licensee is advised to update the records on CDPH 286. LPA observed Notification of Parents’ Rights is in each child’ file, 15 min. sleeping check logs for infants under 2 years old, but missing Individual Infant Sleeping Plan under 12 months old.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LEI, XIAO	FACILITY NUMBER: 434415400
	VISIT DATE: 04/09/2024

NARRATIVE

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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 stated that they do not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

During the exit interview, the licensee, Xiao Lei confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Three deficiencies were cited. A notice of site visit was given and must remain posted for 30 days. The report was discussed and verbally translated into Chinese during the exit interview with Licensee, Xiao Lei.

SUPERVISOR'S NAME: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/09/2024 03:23 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LEI, XIAO	FACILITY NUMBER: 434415400
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1597.622(a)(1)

General Provisions and Definitions

(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year. 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 as a helper was missing TB & Pertussis immunizations which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit the missing records to the office prior to the POC due date.

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. 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 abovesome chidlren in care were mising immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit the missing records to the office prior to the POC due date.

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: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/09/2024 03:23 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: LEI, XIAO	FACILITY NUMBER: 434415400
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. 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 an infant under 12 months old was missing Individual Infant Sleeping Plan (LIC 9227) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2024
	Plan of Correction
1 2 3 4	Licensee agreed to submit the missing records 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: Gladys Kuizon	TELEPHONE: (510) 566-5850
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC809 (FAS) - (06/04)

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