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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 12:30:23 PM

Substantiated


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:
12:00 PM
MET WITH:Dan (Nicole) XiongTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Licensee did not report Unusual Incident(s) to the Department.
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 allegatiotn. 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.

Licensee admits she did not report nor submit Unusual Incident Reports (UIR's) to the department in a timely manner. Licensee stated she was waiting for her friend (who was out of town) to help translate and fill out form LIC 624.
Continued on LIC9099-C...
Substantiated
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 3
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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page 2...

LPA Beckby provided form LIC 624B (Chinese) UIR, in Chinese and was reminded of the required procedures when reporting a UIR. Licensee stated she understood and submitted UIR's for both injuries on 11/2/23.

Based on the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED.

LPA Beckby informed Licensee, Dan (Nicole) Xiong, this report dated November, 29, 2023 documents a Type B citation which poses a potential risk to the health, safety, or personal rights of children in care. An exit interview was conducted with the licensee. 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.
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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
101212(d)(1)(2)(B)
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...a report shall be made to the Department... within the Department's next working day... Any injury to any child that requires medical treatment...a written report shall be submitted to the department within seven days...This requirement was not met as evidenced by:
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LPA provided Licensee Form 624B in Chinese for future events. Licensee stated they will report to CCLD within 24 hours and submit the physical UIR within 7 days. Licensee was given the general email for UIR submitting:
CCLPSAC@DSS.CA.GOV
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Based on record review and interview, CCLD did not receive notification of the unusual incidents that occurred, requiring medical attention, within 24 hours of the event happening. This poses a potential health, safety, or personal rights risk to children in care.
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Licensee will submit UIR's for 2 incidents that occurred in September and October of 2023.
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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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3