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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415676
Report Date: 12/06/2019
Date Signed: 12/06/2019 12:10:23 PM

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:XU, LIFACILITY NUMBER:
434415676
ADMINISTRATOR:XU, LIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 406-6780
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:14CENSUS: 9DATE:
12/06/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Li XuTIME COMPLETED:
12:25 PM
NARRATIVE
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Licensing Program Analyst(LPA) Oscar Huang met with licensee Li Xu for an unannounced case management inspection. LPA explained the nature of today's inspection to licensee. Present were three fingerprinted clearance assistants, Guoying Xin, Yuexian Wang & Ariana Saha and 9 day care children (4 infants & 5 preschool) in the home during today's inspection. The adults who reside in the home are licensee and her parents.

LPA toured the indoor and outdoor areas of the the home during today's inspection.PA observed the home appears clean and orderly, with heating and ventilation for safety and comfort of the children. Temperature was measured at 70 degree F by the thermostat on the wall. LPA observed no baby walker, bouncers, excer-saucers, jumper etc. on the premises. LPA discussed with licensee regrading child sudden death symptom, and infant accessary equipment recalls.

The purpose of this inspection is to ensure that an individual who is on the immediately remove list associated with the facility who can not work, reside, or be present in the facility unless a criminal record exemption is granted. The facility is in compliance with the regulation during today's inspection.

No Deficiency was cited. Exit interview conducted with licensee. A NOTICE SITE VISIT WAS ISSUED, POSTED NEAR ENTRANCE TO THE HOME, AND MUST BE REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2019
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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