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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 344500802
Report Date: 11/29/2023
Date Signed: 11/29/2023 12:29:00 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/27/2023 and conducted by Evaluator Corina Beckby
COMPLAINT CONTROL NUMBER: 53-CC-20231027101128
FACILITY NAME:XIONG, DANFACILITY NUMBER:
344500802
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Dan (Nicole) XiongTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Due to lack of supervision, children sustained injuries
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Corina Beckby met with Licensee, Dan (Nicole) Xiong, to deliver findings for the above complaint allegation. Language LInk Interpreter #16632 and LIcensee's friend Ying Chan was used to translate in Mandarin.

During the investigation, LPA toured the inside and outside of the facility, observed interactions with children in care, conducted interviews with Licensee, 1 parent, and neighbors, obtained pertinent documents, and took pictures.

It was alleged children sustained injuries due to lack of supervision. LPA's observation and interviews with staff and parents did not reveal a supervision concern at the facility. There were 2 separate falls (1 inside and 1 outside), each resulting in elbow fractures. Toys that caused the falls were removed.

REPORT CONTINUES ON LIC9099-C...
Unsubstantiated
Estimated Days of Completion: 31
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 53-CC-20231027101128
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: XIONG, DAN
FACILITY NUMBER: 344500802
VISIT DATE: 11/29/2023
NARRATIVE
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Additionally, Licensee has removed trampoline from backyard and has added artificial grass in the backyard. Licensee was advised to add cushioned padding underneath the small slides. Licensee and her parents were supervising during both instances.

Based on lack of clear corroborating evidence, the above allegation could not be substantiated or dismissed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the finding is UNSUBSTANTIATED.


An exit interview was conducted in which the report was reviewed and discussed with the Licensee, Dan (Nicole) Xiong. LPA provided a copy of the report and Appeal Rights to Licensee. A Notice of Site Visit was posted by LPA and Licensee understands it must remain posted for 30 days. A Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2