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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415676
Report Date: 06/29/2021
Date Signed: 06/29/2021 02:48:08 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: 8DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Li XuTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang met with Licensee, Li Xu for an unannounced required annual inspection. LPA explained the nature of today’s inspection to Licensee. LPA also observed an assistant and 8 day care children (four infants, four preschoolers) in the home during today's inspection. Days and hours of operation are Monday to Friday, 8:00 a.m. to 6:30 p.m. The adults that reside in the home is Licensee.

Family Child Care Home Key Indicator Tool (KIT) #1 was used for the inspection.

A review of staff records on today indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also 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. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12-month period. Licensee understands upon notice of the Department to remove an individual from the home, or to exclude an individual from the home, Licensee shall immediately remove the individual and prevent them from returning to the home or having contact with children in care.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that 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 thermostat on the wall. LPA observed no baby walker on the premises. LPA observed a blocked fireplace. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. LPA observed bathrooms cabinets were locked, kitchen was gated from entering. LPA observed all sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items are stored inaccessible to children. Licensee states there are no weapons/firearms in the home. LPA observed a fenced backyard and no bodies of water. LPA observed a locked storage shed in the fenced off area. Off limit areas outside the home: gated right side yard and backyard where the storage shed is. Licensee rents the house, and has child care liability insurance with Assure Child Care, #20007729. LPA observed Licensee has current CPR and First Aid certification expiring 09/2021. LPA observed a current roster of the children. The last fire drill was conducted on 06/02/2021. LPA reviewed all 8 children files, that are required by regulations such as Immunization records are maintained and up-to-date, and updated and Notification of Parents’ Rights.
Facility Evaluation Report dated 06/29/2021 to be continued on next page:
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: XU, LI
FACILITY NUMBER: 434415676
VISIT DATE: 06/29/2021
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Facility Evaluation Report dated 06/29/2021 to be continued from previous page:
Supervision of children was discussed with Licensee, and she understands that their must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands their capacity options. Licensee states that their do not transport children via vehicle but their understand that children cannot be left in parked vehicles unattended at any time. LPA reviewed safe sleep policies for the infants with the Licensees and provided Licensee "A Child Care Provider's Guide to Safe Sleep” document as well as the most recent PIN 20-24-CCP for Infant SafeSleep and the requirement for checking and logging during the nap in every 15 minutes, including LIC 9227 for infants under one year old. More information can be founded at http://www.cdss.ca.gov/inforesources/Child-Care-Licensing. LPA observed nap records and safe sleep plan for all infants under two year old and safe sleeping plan for under 1 year old. LPA advised licensee that it is requested that child above 2 years old to wear mask by CDPH guidance during the pandemic period.

LPA discussed AB 2231: Civil Penalty Updates effective July 1, 2017 with Licensees. A $500 immediate civil penalty and $100 per day violation until corrected is assessed for serious violations such as absence of supervision, accessible bodies of water, accessible firearms, refused entry of licensing staff, presence of an excluded person, and violations that result in illness or injury. A $100 per day for each violation for Failure to Correct, and $250 immediately and $100 per day per violation until corrected for Repeat Violations.

LPA discussed SB 792 Immunization Requirement with Licensee & helper. LPA observed appropriate records for immunizations against measles, pertussis, and influenza for them in file. Incidental Medical Services (IMS) were discussed with Licensee. Licensee is not providing IMS at this time. 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: http://www.ada.gov/childqanda.htmLicensee will submit a plan of operation for IMS if in the future they provide any IMS to a child in care.

LPA discussed Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. The training web site is available at: https://mandatedreporterca.com/ . Both Licensee and her helper requested to be exempted from training due to English is not her primary language.

No Deficiency was cited. Exit interview conducted with Licensee. A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST 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: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
LIC809 (FAS) - (06/04)
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