434415676-12-9-2021-07-CC-DSTN-CB9UCT-20220202142824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434415676
Report Date: 12/09/2021
Date Signed: 12/09/2021 10:19:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2021 and conducted by Evaluator Yangcheng Huang

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20211203141338

FACILITY NAME:	XU, LI		FACILITY NUMBER:	434415676
ADMINISTRATOR:	XU, LI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 406-6780
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95051
CAPACITY:	14	CENSUS: 6	DATE:	12/09/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Li Xu		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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PPE is not being worn on the facility grounds

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Oscar Huang made a 10-day initial complaint investigation to the facility. LPA met with Licensee, Li Xu, and discussed the above allegation with her. During the visit, LPA observed 3 staff and 6 children (4 infants & 3 preschoolers). LPA interviewed licensee, and copies of pertinent documents were also obtained.

Based on interview of Licensee and LPA's own observations for the complaint allegation listed above. LPA concludes that the preponderance of evidence standard has been met and the allegation listed above is therefore SUBSTANTIATED. Advisory Note is being issued on the attached LIC 9102.

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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sandy Knight	TELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Yangcheng Huang	TELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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