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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500802
Report Date: 07/29/2024
Date Signed: 07/29/2024 11:26:22 AM

Document Has Been Signed on 07/29/2024 11:26 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:XIONG, DANFACILITY NUMBER:
344500802
ADMINISTRATOR/
DIRECTOR:		XIONG, DANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 397-3652
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 4DATE:
07/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Dan XiongTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst's (LPA's) Corina Beckby and David Nguyen met with Licensee, Dan Xiong, to follow up on the Unusual Incident Reports (UIR) submitted to Community Care Licensing on 07/27/24.

LPA toured the facility, observed the care and supervision of children, and conducted an interview.

Facility evaluation report was reviewed and discussed with Licensee. Exit interview was conducted. A Notice of Site Visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today's inspection.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2024
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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