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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409466
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:40:51 PM

Document Has Been Signed on 08/23/2024 03:40 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:XI, SHANSHANFACILITY NUMBER:
073409466
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
08/23/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:10 PM
MET WITH:XI, SHANSHANTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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THIS IS AN AMENDED DOCUMENT FROM THE ORIGINAL DATED JULY 10, 2024.

On July 10, 2024 at 1:30PM Licensing Program Analyst (LPA) Nyeesha Blount conducted an unannounced case management/increase of capacity inspection. Present during the inspection was the licensee and (4) preschool aged children in care. Licensee has an approved fire clearance for up to 14 children dated 06/25/24.
LPA toured the facility for a health and safety inspection. The On Limit areas will be the living room, (1) bedroom, (1) bathroom and backyard. The Off Limit areas will be the kitchen, (1) bedroom, (1) bathroom and garage secured with gate and latches made inaccessible to children in care . There are age appropriate toys in the home. There are no pools, hot tubs or any other similar bodies of water at this home. There are no firearms in the home as stated by the licensee. LPA did not observe any hazardous materials or toxins accessible to children today. The home is equipped with a working smoke detector and carbon monoxide detector. There is a working telephone in the home. The home has a fully charged 2A10BC fire extinguisher.
Licensee owns the home, a copy of the mortgage statement was reviewed.

LPA reviewed the ratio and capacity requirements for a large family child care home. Licensee understands that if an assistant is not present she must follow the ratio and capacity for a small family child care home.
Notice of Site Visit was provided and must be posted for 30 days.
Exit interview and report reviewed with Xi, Shanshan.
The requested increase of capacity to care for up to 14 children was not approved effective July 10, 2024. Fire Clearance was not signed.
SUPERVISORS NAME: Mayla Mendoza
LICENSING EVALUATOR NAME: Nyeesha Blount
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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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