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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423832
Report Date: 10/25/2022
Date Signed: 10/25/2022 04:21:40 PM

Document Has Been Signed on 10/25/2022 04:21 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:XI, NAFACILITY NUMBER:
013423832
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 5DATE:
10/25/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Na XiTIME COMPLETED:
04:35 PM
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On 10/25/2022 Licensing Program Analyst (LPA) Arminder Singh met with Licensee, Na Xi and her fingerprint cleared Husband for an Unannounced Capacity Increase inspection. Licensee is applying for a Large Family Child Care Home License. There are 5 children present today. Days and hours of operation are Monday thru Friday 8:00 AM to 6:00 PM.

The home is a two story home. The home consists of three bedrooms, three and half bathrooms, living room (classroom), dining area, kitchen, and backyard.

IN USE AREAS: The living room (classroom), dining room, two bathrooms located on first floor (one bathroom is full bath and other is a half bathroom), bedroom located on first floor which is located towards the back of the home, and outdoor play area.

OFF LIMIT AREAS: The kitchen and entire second floor which has two bedrooms, two bathrooms, and laundry room. The second floor is made inaccessible by a gate/barricade.

Outdoor Area: Outdoor play area is fully fenced. The outdoor play area has a padded surface. The outdoor play area does have a locked shed towards the back of the outdoor play area. Licensee understands that the shed shall be made inaccessible when children are outdoors. The Licensee understands 100% visual supervision is required.

CONTINUED ON NEXT PAGE
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: XI, NA
FACILITY NUMBER: 013423832
VISIT DATE: 10/25/2022
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The home is sanitary, safe and orderly, with central heating and ventilation for safety and comfort. LPA observed required Postings on the wall. LPA observed: fully charged 2A10BC fire extinguisher, working smoke and carbon monoxide detectors all over the home. Medicines, cleaning products, sharp objects are stored inaccessible to children in cabinets and out of reach of children. LPA reminded Licensee that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes. Licensee states there are no pets in the home. Licensee states there are no firearms and ammunition stored in the home.

The Licensee has current CPR and First Aid certification. The Licensee was reminded to conduct and document fire and earthquake drills at least once every six months. LPA reminded Licensee that the mandated reporter training certificates are to be renewed every two years.

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: http://www.ada.gov/childqanda.htm
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: XI, NA
FACILITY NUMBER: 013423832
VISIT DATE: 10/25/2022
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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.

LPA discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensees 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.

The Home is Recommended for Capacity Increase effective 10/25/2022.



Exit Interview was conducted, where this report was reviewed and discussed with Licensee. Report was signed by the Licensee confirming receipt of documents.

A NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED ON OR ADJACENT TO THE INTERIOR SIDE OF THE MAIN DOOR INTO THE FACILITY FOR 30 CONSECUTIVE DAYS.

END OF REPORT
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Arminder Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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