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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434416291
Report Date: 09/01/2021
Date Signed: 09/01/2021 03:44:34 PM

Substantiated


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
06/28/2021 and conducted by Evaluator Yangcheng Huang
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20210628161408
FACILITY NAME:MOCK, LI-FANFACILITY NUMBER:
434416291
ADMINISTRATOR:MOCK, LI-FANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 208-1097
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 4DATE:
09/01/2021
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Li-Fan MockTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not wear a mask
Child received injury while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Oscar Huang, conducted an unannounced complaint investigation to the Facility today to deliver investigation findings. LPA met with Licensee, Li-fan Mock, and explained the nature of today's visit to her.

Based on interviews of Licensee, staff & complainant, reviews child, facility records & evidences, and LPA's own observations for the complaint allegations listed above.

LPA learnt that on one occasion, a staff took a photo while holding a child without wearing mask. On other ocasion a child start learning to walk suddenly tripped, fell, and hit another child who sitting on carpet then hit a toy sets cuasing a minor red mark on her forehead near the corner of her right eye.

LPA therefore concludes that the preponderance of evidence standard has been met and the allegation listed above is therefore SUBSTANTIATED. Advisory Notes are being issued on the attached LIC 9102s.

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:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
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
06/28/2021 and conducted by Evaluator Yangcheng Huang
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20210628161408

FACILITY NAME:MOCK, LI-FANFACILITY NUMBER:
434416291
ADMINISTRATOR:MOCK, LI-FANFACILITY TYPE:
810
ADDRESS:14815 LOS GATOS-ALMADEN ROADTELEPHONE:
(650) 208-1097
CITY:SAN JOSESTATE: CAZIP CODE:
95124
CAPACITY:14CENSUS: 4DATE:
09/01/2021
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Li-Fan MockTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notify authorized representative of child's diaper rash
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Oscar Huang, conducted an unannounced complaint investigation to the Facility today to deliver investigation findings. LPA met with Licensee, Li-fan Mock, and explained the nature of today's visit to her.

Based on interviews of Licensee, staff & complainant, reviews child, facility records & evidences, and LPA's own observations for the complaint allegation listed above. It could not be proved or disproved.

LPA therefore concludes that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations is UNSUBSTANTIATED.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 FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3