<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015701269
Report Date: 04/23/2025
Date Signed: 04/24/2025 11:53:59 PM

Document Has Been Signed on 04/24/2025 11:53 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:XU, FULIFACILITY NUMBER:
015701269
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/23/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Fuli XuTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On April 23rd, 2025, at 9:45am, Licensing Program Analyst (LPA) April Wright met with applicant Fuli Xu for an announced pre-licensing visit to conduct a health and safety inspection. The applicant was the only individual present during the inspection. Applicant speaks Mandarin and translation services were used during the inspection. Hours of operation will be from 8:00am to 6:00pm, Monday through Friday.

The applicants’ home is single-story was neat and orderly with heating and ventilation to provide safety and comfort . Home consists of three (3) bedrooms including master bedroom, two (2) bathrooms including a master bathroom, Living room, family room area, dining area, kitchen, garage, and backyard. The home has a 2A10C fire extinguisher and has functioning carbon monoxide/smoke detectors. Applicant has a fully stocked first aid kit located in the hallway storage closet opposite the master bedroom. LPA reviewed documentation that was submitted that confirms the applicant is renting the property.

On Limits: The areas of the day care will consist of the living/family room areas (main day care areas, upon entry to the home), bedroom #1/day-care room #2(down hallway to the left), bathroom (to the left upon entry to the home), and portion of the backyard.

Off Limits: Bedrooms #2 and #3, master bathroom, left portion of the backyard(gated/inaccessible to children) kitchen and garage. Off limits areas are made inaccessible by child safety gates and child safety locks to prevent access to those areas. LPA observed the backyard was free from visual defects, hazards, damage or dangerous conditions. There are age appropriate toys for the children to utilize and observed by the LPA to be free of visual defects or damage. LPA observed and applicant confirmed that there are no pools, hot tubs, or any other visible bodies of water on the premises. Applicants confirmed there are no pets located in the home. See LIC809C for continuance.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: April Wright
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2025
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 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: XU, FULI
FACILITY NUMBER: 015701269
VISIT DATE: 04/23/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA observed and applicant confirmed that all hazardous materials, toxins and cleaning products are made inaccessible to children in care. Applicant has installed child safety locks on the cabinets, drawers and doors as observed by the LPA. LPA observed and applicant confirmed there are no firearms or weapons in the home.

Applicant completed the Preventive Health and Safety training on 5/21/2022. CPR/First Aid training certificates are current and will expire on 12/2025. Mandated Reporter training was completed on 3/26/2024. Applicant is following all immunization laws as it pertains to all day-care providers. A packet of forms pertaining to the children’s files and facility files were reviewed and discussed. LPA Wright discussed the Safe Sleep practices with applicant.

LPA Wright reminded the applicant of the following: Mandated Reporter training and CPR/First Aid training certificates must be renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility. LPA discussed Unusual Incidents Reports with the applicant and when to report an incident. LPA discussed with the applicant that the Family Child care home licenses issued by CCLD are not transferable to any additional locations. The applicant is also reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

LPA Wright provided a copy of Safe Sleep-in Child-Care brochure, a handout "What Does A Safe Sleep Environment Look Like?" and a copy of the new California Car Seat Law Changes. For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list.

Applicant is reminded that all assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Applicant was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov

See LIC809C for continuance.
NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: April Wright
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: XU, FULI
FACILITY NUMBER: 015701269
VISIT DATE: 04/23/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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

This home is recommended for licensure. This report shall remain on file for 3 years. Report was reviewed and read with applicant Fuli Xu.
NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: April Wright
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4