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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846313
Report Date: 04/22/2024
Date Signed: 04/22/2024 02:13:25 PM

Document Has Been Signed on 04/22/2024 02:13 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:SONG FAMILY CHILD CAREFACILITY NUMBER:
334846313
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
04/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Zixuan SongTIME VISIT/
INSPECTION COMPLETED:
02:30 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 04/22/2024 at 9:30 AM, Licensing Program Analyst (LPA) Tiffanie Diep arrived at the facility to conduct an annual inspection. LPA toured inside and outside of the home, reviewed records, and observed and/or discussed the following:
  • Licensee Zixuan Song’s parent/assistant (S2) was also present during the inspection.
  • Normal days and hours of operation are: Monday through Friday from 8:00 AM to 6:00 PM.
  • Per Licensee’s request, the off-limits areas will now include: the office, bedroom/bathroom, both garages, and backyard on the first floor and master bedroom/bathroom, laundry room, and two bedrooms at the end of the hallway on the second floor.
  • Appropriate supervision was provided during the inspection.
  • A working telephone was present with current number on file.
  • An appropriate fire extinguisher and smoke detector were present and tested by Licensee during the inspection. The carbon monoxide detector was not functioning during the inspection.
  • Licensee stated they do not use the fireplace and will maintain supervision to ensure children's safety.
  • All hazardous items were stored inaccessible to children.
  • Toxins were locked.
  • There are no weapons present in the home per Licensee. Licensee understands all firearms, weapons, and ammunition must be locked separately and made inaccessible to children in care according to Title 22 Regulations.
  • Stairs were barricaded by a baby gate.
  • Verification of control of property on file (Deed).
  • Property Owner/Landlord Notification (LIC 9151) and Property Owner/Landlord Consent Form (LIC 9149) on file.

Continues on LIC 809-C
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SONG FAMILY CHILD CARE
FACILITY NUMBER: 334846313
VISIT DATE: 04/22/2024
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
Continued from LIC 809 (Page 2)
  • Facility sketches, Emergency Disaster Plan (LIC 610A), and Notification of Parents' Rights poster (PUB 394) were posted.
  • Preventive health and safety training was completed on 10/26/2022.
  • Pediatric CPR and first aid certification expires on 02/17/2026.
  • Mandated Reporter Training certificate expires on 10/18/2024.
  • There is an empty fountain located in the backyard. Licensee confirmed there are no bodies of water on the premises at this time. Licensee understands all bodies of water, including in-ground and above-ground pools, hot tubs, spas, and ponds, must be inaccessible to children in care and be properly covered or fenced according to Title 22 Regulations. The Department must be notified prior to installation of these and similar bodies of water.
  • Clean, safe, and age-appropriate toys were present.
  • A current roster of children on file.
  • Documentation of fire and disaster drills on file; last drill was conducted on 12/20/2023.
  • Children’s records were not complete. LPA did not observe Consent For Emergency Medical Treatment (LIC 627) forms were maintained for five out of five children.
  • Staff records were complete.
  • Licensee was informed of their reporting requirements and was provided with the Regional Office’s Unusual Incident Reporting e-mail at UnusualIncidentReportsDO09@dss.ca.gov.
  • Licensee can submit transfer forms to associate new individuals or to disassociate someone from their facility via e-mail to Associations_Disassociations862@dss.ca.gov.
  • The Duty Officer is available to answer questions Monday through Friday from 8:00 AM to 5:00 PM at (951) 782-4200.
  • Resident and/or staff records reviewed during today’s inspection indicate that all adults who require caregiver background checks have received all required clearances or exemptions.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SONG FAMILY CHILD CARE
FACILITY NUMBER: 334846313
VISIT DATE: 04/22/2024
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
Continued from LIC 809-C (Page 3)

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of five days or, if the penalty is for a repeat violation, for a maximum of 30 days 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 webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed Licensee 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 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) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at https://www.ada.gov/resources/child-care-centers/.

To improve the quality and value of the new inspection process, a survey may be sent to the e-mail address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE Tool, please send e-mail inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at https://www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process. Licensee was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: SONG FAMILY CHILD CARE
FACILITY NUMBER: 334846313
VISIT DATE: 04/22/2024
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
Continued from LIC 809-C (Page 4)

See attached LIC 9102 for advisory note. Based on LPA’s observations, interviews conducted, and records reviewed, a deficiency is being cited on the attached LIC 809-D. LPA Tiffanie Diep informed the licensee, Zixuan Song, that this report dated 04/22/2024 documents one Type B citation as there was a potential risk to the health and safety of children in care.

An exit interview was conducted and report was reviewed with the licensee, Zixuan Song. During the exit interview, Licensee confirmed that there are no registered sex offenders (RSO) living in the facility and LPA completed the RSO profile in the Field Automation System. A notice of site visit was given to Licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 04/22/2024 02:13 PM - It Cannot Be Edited


Created By: Tiffanie Diep On 04/22/2024 at 01:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: SONG FAMILY CHILD CARE
FACILITY NUMBER: 334846313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, interviews conducted, and records reviewed, the licensee did not comply with the section cited above as licensee did not ensure Consent For Emergency Medical Treatment (LIC 627) forms were completed and maintained for five out of five children which poses a potential health and safety risk to children in care.
POC Due Date: 05/22/2024
Plan of Correction
1
2
3
4
LPA discussed the requirement to maintain each child's authorized representative's authorization to consent to emergency medical care at the facility. Licensee agreed to provide copies of completed LIC 627s for each child to LPA by 05/22/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Aaron Ross
LICENSING EVALUATOR NAME:Tiffanie Diep
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6