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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416353
Report Date: 03/21/2022
Date Signed: 03/21/2022 02:49:29 PM


Document Has Been Signed on 03/21/2022 02:49 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:ZHOU, XINFACILITY NUMBER:
434416353
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
03/21/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Xin ZhouTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Oscar Huang met with Licensee Xin Zhou for an unannounced case management inspection due to licensee's capacity increase request and post inspection visit. LPA explained the nature of today’s inspection to Licensee. LPA observed no daycare children in the home during today's inspection. Licensee stated she currently does not have any enrollment. She wil have children enroll starting next week. Days and hours of operation are Monday to Friday, 8:00 a.m. to 6:00 p.m. The adults that reside in the home are Licensee & her husband.

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. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

The Licensee agreed to give LPA a tour of the home both indoor/outdoor during today's tele-inspection. The entire home was inspected for health and safety hazards. LPA observed no stairs inside the home. The main area of the home is used for the day care are Living Room, Dinning Room, Kitchen, and Bathroom #1. LPA observed screen fireplaces. Off limit areas inside the home: all four bedrooms, master bathroom, and garage. LPA observed at least one combined functioning smoke detector, a full charged 2A-10BC fire extinguisher. Off limits outdoor are two blocked side yards. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA observed a hand gun & a shot gun stored in a locked safe box, and animation stored separately in another safe box in different location and no pets. Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Licensee that smoking, drop side cribs, and baby walkers, bouncers, excer-saucers, jumpers etc. are not allowed in Family Child Care Homes. Licensee observed 68 degrees on the thermostat, Licensee was advised to keep temperature within 68-85 degrees.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2022
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: ZHOU, XIN
FACILITY NUMBER: 434416353
VISIT DATE: 03/21/2022
NARRATIVE
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LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items are stored in areas inaccessible to children.

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-and-resources/safe-sleep as an additional resource. LPA also informed Applicant 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.

Incidental Medical Services (IMS) policy was discussed. 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: https://www.ada.gov/childqanda.htm



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. Licensee has completed her child care provide training and general training on 09/01/2021 & 02/24/2022, and copy of the certifications are on file.

LPA discussed SB 792 Immunization Requirement with Licensee. LPA observed appropriate records for TB test, immunization against measles, pertussis, and influenza for Licensee on file.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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: ZHOU, XIN
FACILITY NUMBER: 434416353
VISIT DATE: 03/21/2022
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LPA reviewed COVID-19 infection prevention guidance & self-assessment with Licensee including the plans in place to protect and to support staff &children, as well as essential protective equipment and supplies, cleaning & hygiene implementation, arrival procedures, health screening & social distancing practices and meal times.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

LPA reviewed with Licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA advised Licensee that beginning January 1, 2019, AB2370 requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families.



A fire clearance granted from the San Jose Fire Department on 3/4/2022, received 3/15/2022 and a copy was on file: Living Room & Back yard for approved for daycare, All bedrooms & garage are off limit. * Fire Clearance Granted.

LPA conducted an exit interview, reviewed the report, and advised the Licensee, Xin Zhou that her large Family Child Care Home license is now pending on the management approval.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Yangcheng HuangTELEPHONE: 408-334-8321
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
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