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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500802
Report Date: 12/01/2025
Date Signed: 12/01/2025 01:24:29 PM

Document Has Been Signed on 12/01/2025 01:24 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
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: 12CENSUS: 10DATE:
12/01/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Dan XiongTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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Interpretation services were provided by Operator #38839087 in Mandarin by the Department of Social Services Interpreting service, as well as Licensee's friend Ying Chan.

Licensing Program Analyst (LPA) Corina Beckby met with Licensee, Dan Xiong, to follow up on the Unusual Incident Report (UIR) emailed to Community Care Licensing on November 17, 2025. During today's inspection LPA toured the facility, conducted interviews with staff and obtained information pertinent to the incident.

The facility self-reported the UIR to Community Care Licensing within 24hrs and submitted a written UIR within 7 days. On 11/17/2025, Child #1 lost her balance and hit her head on the floor. Per the report and interview, Child #1 “exhibited sings of fatigue including dozing off multiple times…”. Child #1 was not offered a place to rest prior to the incident, despite falling asleep “during structured class activities and once during lunch”. Licensee assessed Child #1, noticed an injury to the face and called parents.

Based on the interview and information obtained, a Title 22 Deficiency has been issued on the attached LIC 809-D. The facility was informed that this report dated 12/01/2025, documents one Type A citation which shall be posted for 30 consecutive days. The facility shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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

NAME OF LICENSING PROGRAM MANAGER: Bettina Engelman
NAME OF LICENSING PROGRAM ANALYST: Corina Beckby
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/01/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 12/01/2025 01:24 PM - It Cannot Be Edited


Created By: Corina Beckby On 12/01/2025 at 08:27 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: XIONG, DAN
FACILITY NUMBER: 344500802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/02/2025
Section Cited
CCR
102423(a)(4)

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Personal Rights (a)(4) Each child receiving services...have certain rights...To be free from…actions of a punitive nature, including, but not limited to: interference with eating, sleeping or toileting…This regulation was not met by....
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Technical Support Program brochure was provided and Supervising Children in Care and Children’s Personal Rights videos on the Department of Social Services website.
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Licensee self reported that Child #1 exhibited sings of fatigue including dozing off multiple times in the morning, and the child was not offered a place to rest prior to the incident, which is an immediate health and safety risk to the children in care.
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 Licensee will offer a place to rest and call parents to see if their child is not feeling well, did not get enough rest or anything else. Licensee will continue to get a verbal report from the parents regarding their childrens' physical status. Licensee will submit a statement saying she followed the plan of correction.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bettina Engelman
NAME OF LICENSING PROGRAM MANAGER:
Corina Beckby
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2025


LIC809 (FAS) - (06/04)
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