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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500802
Report Date: 06/16/2023
Date Signed: 06/16/2023 04:20:09 PM

Document Has Been Signed on 06/16/2023 04:20 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:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
06/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Dan XiongTIME COMPLETED:
03:45 PM
NARRATIVE
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During the visit to the facility on 06/16/2023, the following was observed.

Licensing Program Analyst (LPA) toured the facility, observed Licensee and children in care, obtained pertinent documents and conducted interviews. LPA used language Link to help translate and Licensee’s friend Ying Chan.

Roster was reviewed and Children’s files were reviewed but incomplete.

LPA Beckby informed licensee, Dan Xiong, that this report dated June 16, 2023, documents a Type B citation issued during today's inspection, this poses a potential risk to the health, safety, of children in care.



An Exit Interview was conducted, and the report was reviewed with Licensee, Dan Xiong. A Notice of Site visit was posted by LPA and must remain posted for 30 days. 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: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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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Document Has Been Signed on 06/16/2023 04:20 PM - It Cannot Be Edited


Created By: Corina Beckby On 06/16/2023 at 03:12 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: XIONG, DAN
FACILITY NUMBER: 344500802

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/17/2023
Section Cited
CCR
102421(b)

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102412(b) Children's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required in Section 102417(g)(7).

This requirement is not met as evidenced by
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Licensee will collect all required forms and documents from all families enrolled and future families. Licensee will maintain a file for each child and keep it for record review for up to three years.
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Based on interview and file review, 8 of 8 children's files were missing Medical Consent forms, Liability Forms, and/or Parent's Rights, which poses a potential Healh, Safety and/or Personal Rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Bettina Engelman
LICENSING EVALUATOR NAME:Corina Beckby
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2023


LIC809 (FAS) - (06/04)
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