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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700404
Report Date: 10/31/2022
Date Signed: 10/31/2022 11:46:00 AM

Document Has Been Signed on 10/31/2022 11:46 AM - 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:LIU, XIAOHUAFACILITY NUMBER:
015700404
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/31/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Xiaohua LiuTIME COMPLETED:
11:44 AM
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On 10/31/2022 at 10:09pm Licensing Program Analyst (LPA) Morgan Pringle met with applicant Xiaohua (Eva) Liu for an Announced Pre-Licensing Visit. LPA used Language Links interpreter #13891 for this inspection. Present during the inspection was the applicant. Applicant lives in the home with her husband, Canming Mai, and their three (3) minor children. The applicant’s home was toured for a health and safety inspection. The facility plans to operate 6am – 9pm, Monday – Saturday.

ON LIMITS AREA: Living Room, Playroom, Downstairs Bathroom, Play Yard (portion of the outside yard next to the playroom), small potion of driveway.


OFF LIMITS AREA: Entire 2nd Floor, Living Room next to the Dining Area, Kitchen, Downstairs Study Room, Balcony on the side of the kitchen and Garage
ISOLATION AREA: Playroom

The home is two story home owned by the applicant. The first floor consists of two (2) living rooms, kitchen, dining area, laundry room, playroom, study room, bathroom and a balcony that is attached to the kitchen. The second floor consists of the master bedroom and bathroom, two (2) bedrooms and a bathroom. The outside of the home consists of a driveway and a small enclosed area (play yard). Applicant stated that a small portion of the driveway will be used, but only when there is a few children.

The inside and outside of the home are observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. All off limit areas are gated and/or locked. The stairs in the home leading to the second floor is gated and the stairs leading to the back of the home has an electronic security lock on the door. The fireplace in the living room that is on-limits, is not in use and blocked. Applicant has stated that there are no firearms and no pets in the home. The home has centralized heat and air for proper ventilation. LPA did not observe any harmful bodies of water in or around the home. Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LIU, XIAOHUA
FACILITY NUMBER: 015700404
VISIT DATE: 10/31/2022
NARRATIVE
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There is a working smoke detector in dining area, the study room, both living rooms, and all bedrooms. There is a working carbon monoxide detector in the downstairs hallway leading to the laundry room and in the living room. There are two (2) 2A10BC fire extinguishers in the home, one (1) in the downstairs closet and one (1) at the top of the stairs. The applicant’s Health and Safety training with the lead poisoning component has been completed and CPR and First Aid certificate is current and expires on 7/10/2023. Mandated Reporter training is complete and expires on 10/2/2024. Applicant has provided proof of immunization for pertussis, measles, and the flu shot. All adults living in the home have obtained a criminal record clearance. LPA provided technical assistance on criminal record clearances.

Applicant was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed the applicant that all forms can be downloaded at www.ccld.ca.gov. Applicant was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Applicant was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Applicant is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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.


Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LIU, XIAOHUA
FACILITY NUMBER: 015700404
VISIT DATE: 10/31/2022
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Applicant 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 Applicant 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: http://www.ada.gov/childqanda.htm.

LPA reviewed with Applicant the LIC311D, Forms/Records To Keep In Your Family Child Care Home, Children’s Forms/Records, Facility Forms/Records, and Information to be Posted.

Entrance checklist was provided to the Applicant.

Exit interview conducted and report was reviewed with the Applicant Xiaohua Liu.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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