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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500802
Report Date: 05/31/2024
Date Signed: 05/31/2024 12:04:19 PM

Document Has Been Signed on 05/31/2024 12:04 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: 9DATE:
05/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Dan XiongTIME VISIT/
INSPECTION COMPLETED:
12:45 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 5/31/24, Licensing Program Analyst (LPA) met with Licensee, Dan Xiong for a case management and learned that on 5/28/24, Licensee left daycare children (for a medical emergency) with 2 assistants who are not CPR certified.

LPA informed Licensee, Dan Xiong, that this report dated 05/31/24, documents a Type B citation that is a potential Health and Safety, or Personal Rights risk to persons in care. An 809D is issued for the deficiency.

An Exit interview was conducted, and the report was reviewed with Licensee, Dan Xiong LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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 2
Document Has Been Signed on 05/31/2024 12:04 PM - It Cannot Be Edited


Created By: Corina Beckby On 05/31/2024 at 11:41 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: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/01/2024
Section Cited
CCR
102416(c)

1
2
3
4
5
6
7
102416(c) Personnel Requirements... other personnel as specified shall complete training... including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
1
2
3
4
5
6
7
Licensee will write a statement stating she will no longer leave the facility during daycare hours when daycare children are present and/or will have mom take CPR class. Licensee will send CPR certificate if and when mom finishes course.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on file review, the licensee did not comply with the section cited above, where 2 of the 2 assistants are not CPR certified, which poses an immediatel health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Licensee will send CPR certificate if and when mom finishes course.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2