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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409466
Report Date: 10/06/2023
Date Signed: 10/06/2023 11:10:31 AM

Document Has Been Signed on 10/06/2023 11:10 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:XI, SHANSHANFACILITY NUMBER:
073409466
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
10/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:XI, SHANSHANTIME COMPLETED:
12:00 PM
NARRATIVE
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On October 6, 2023 at 09:00AM Licensing Program Analyst (LPA) Nyeesha Blount conducted an announced Pre-Licensing inspection and met with applicant Xi, Shanshan. LPA disclosed the purpose of the inspection and was granted entry into facility by applicant. Present during this inspection was fingerprint cleared Applicant. LPA toured with Applicant for a health and safety inspection. The facility plans to operate Monday – Friday 7:30AM to 5:30PM.

The home is a One story home, which consist of living room, dining room, kitchen, (4) bedrooms, (2) bathrooms, fenced backyard, and garage. The day care is neat and clean and has central heating and ventilation for safety and comfort. There are enough age appropriate furnishings, toys, books and learning materials available. Applicant states there are no weapons in the home. All hazardous materials and toxins were observed to be inaccessible to children today, Knives were stored in an upper cabinet. The day care is equipped with a fully charged 3A40BC fire extinguisher, working smoke detector, and working carbon monoxide detector. Pediatric CPR and First Aid are current and will expire on July 2025.

ON LIMIT: Living room, (1) bedroom, (1) bathroom, back yard.

OFF LIMIT: Kitchen, dining room, (3) bedrooms, (1) bathroom, and garage.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: XI, SHANSHAN
FACILITY NUMBER: 073409466
VISIT DATE: 10/06/2023
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OUTDOOR SPACE: The entire area was inspected to ensure the health and safety of the area. currently there are no play structures. There are no pools. There is a brown hot tub in the left corner of the backyard away from where the children where play. LPA observed there are latches on all four corners that are secured made inaccessible to the children in care. Applicant advsied the hot tub was here when they purchased the home and it has never been used.

ISOLATION AREA: will be in the third bedroom to the right of the hall.

LPA reviewed with applicant, 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

Entrance Checklist was provided to the applicant.

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, licensee, or facility representative] 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.

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.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: XI, SHANSHAN
FACILITY NUMBER: 073409466
VISIT DATE: 10/06/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Licensee was reminded about importance to stay in compliance with mandated reporter training and maintenance of sleep logs for all infants in care.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the licensee Xi, Shanshan.

Licensed effective October 6, 2023.

SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC809 (FAS) - (06/04)
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