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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415676
Report Date: 12/09/2024
Date Signed: 12/09/2024 05:17:16 PM

Document Has Been Signed on 12/09/2024 05:17 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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:XU, LIFACILITY NUMBER:
434415676
ADMINISTRATOR/
DIRECTOR:		XU, LIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 406-6780
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 6DATE:
12/09/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Xu, Li TIME VISIT/
INSPECTION COMPLETED:
05:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kate Huang conducted an unannounced annual inspection with Licensee Li Xu. LPA explained the nature of today’s inspection to the Licensee. Present during the inspection were the Licensee, one helper, and two preschoolers and four infants. The facility's hours of operation are Monday to Friday, from 8:00 AM to 6:00 PM. The only adult residing in the home is the Licensee.

LPA toured both the indoor and outdoor areas of the home during the inspection. Required materials were observed posted near the entrance. Sufficient toys, materials, and play equipment for the daycare children were also observed. The home is equipped with central heating/cooling and ventilation to ensure the comfort of the children.

LPA observed that three infants were in separate bedrooms for sleep. These bedrooms were all closed. The helper, who was outside the bedrooms, stated that she would check on the sleeping infants every 15 minutes. Each infant had their own crib and was using a sleeping bag. However, LPA observed that one infant was sleeping in a bedroom that is not approved for use by the San Jose Fire Department.



LPA observed licensee and the helper have current CPR and First Aid certifications. 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 fire drill was done on 07/08/2024. LPA reviewed 4 children files and staff's records. Licensee can show LPA all the required children's records and can provide the required staff documents including the immunization records.

LPA observed a fully charged fire extinguisher, which was purchased on 11/04/2024, as well as functioning smoke and carbon monoxide detectors. The Licensee stated that there are no weapons in the home.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Linke Huang
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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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Document Has Been Signed on 12/09/2024 05:17 PM - It Cannot Be Edited


Created By: Linke Huang On 12/09/2024 at 04:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: XU, LI
FACILITY NUMBER: 434415676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because three infants were sleeping in three separate bedrooms from where the provider and assistant were stationed, the doors to the rooms the infants were sleeping in all closed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Licensee to submit a written plan of correction by the POC Due Date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Linke Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/09/2024 05:17 PM - It Cannot Be Edited


Created By: Linke Huang On 12/09/2024 at 04:22 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: XU, LI
FACILITY NUMBER: 434415676

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102371(a)
102371 Fire Safety Clearance
(a) A fire safety clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal shall be required for a large family child care home.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because one infant was sleeping in one off-limit bedroom which is not approved by the fire department which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Licensee removed the infant's crib out of the off-limit bedroom during the inspection per LPA's request.
Licensee to submit a written plan of correction and parents' signed LIC 9224 forms by the POC Due Date.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Linke Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: XU, LI
FACILITY NUMBER: 434415676
VISIT DATE: 12/09/2024
NARRATIVE
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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 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-andresources/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.

Licensee stated that they did not provide medicine to children. Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Linke Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: XU, LI
FACILITY NUMBER: 434415676
VISIT DATE: 12/09/2024
NARRATIVE
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LPA Kate informed licensee Xu, Li that this report dated on 12/09/2024 document one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Kate informed the licensee to provide a copy of this licensing report dated on 12/09/2024 that documents any Type A citation(s) to parents/guardians of all
children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

As a result of todays inspection, one type B deficiency was also cited, see LIC809-D. Appeal rights provided to licensee.

A notice of site visit was given and must remain posted for 30 days.

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 confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the licensee, Xu, Li in Mandarin.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Linke Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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