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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500802
Report Date: 03/29/2023
Date Signed: 03/29/2023 04:37:23 PM

Document Has Been Signed on 03/29/2023 04:37 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 SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:XIONG, DANFACILITY NUMBER:
344500802
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
03/29/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dan XiongTIME COMPLETED:
03:15 PM
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On 3/29/2023, Licensing Program Analyst (LPA) Corina Beckby met with Applicant (A1) Dan Xiong for the purpose of a pre-licensing inspection. A friend, Winnie Xiong translated for A1 in Mandarin. LPA provided the Entrance Checklist to A1. All individuals subject to criminal background review have obtained a criminal record clearance verified by LPA accessing Guardian. A1’s tentative hours of care are 8:00 am- 6:00 pm, Monday-Friday.

A health and safety inspection was conducted inside and outside of the FCCH. A1 accompanied LPA for the entirety of the tour. The FCCH is a two-story house with a kitchen, sitting room, living room, dining room, pantry, laundry room, 2 1/2 bathrooms, 4 bedrooms, and garage. LPA observed a fireplace which has tempered glass and will not be used during day care hours. LPA observed the stairs properly barricaded by a baby-gate at the bottom of the stairs. LPA discussed with A1, all poisons must be locked with a key lock or combination lock.

The outdoor play area was toured which has side yards. LPA verified that the entirety of the backyard is fenced-in and walked the perimeter to ensure the safety of the fence and gate. LPA has a trampoline in the backyard that will be used by school age children ages 6 and over under her direct supervision. LPA did not observe any bodies of water. The OFF-limits areas of the FCCH are the pantry, laundry room, entire second floor, the right side of the backyard, front yard, and garage. Off-limits areas will remain inaccessible to children by gates, closed doors and/or supervision. A1 understands that OFF-limit areas must remain inaccessible to children in care.

Functioning smoke and carbon monoxide detectors were observed in the hallway and tested. Personal medication is stored upstairs in a top cabinet in the master bathroom inaccessible to children. A 3A40BC fire extinguisher was observed in a lower cabinet in the kitchen. A first aid kit was observed in the pantry. A1 stated there are no firearms or weapons in the home.


Continued on 809-C
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: XIONG, DAN
FACILITY NUMBER: 344500802
VISIT DATE: 03/29/2023
NARRATIVE
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LPA discussed Mandated Reporter Training with A1. Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their Mandated Reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/. The training is currently provided in English and Spanish.

A1 has a current Mandated Reporter Training Certificate which will expire on 03/06/2025. Current Pediatric CPR and First Aid training was verified and expires on 04/15/2024. Completion of Preventative Health and Safety training including nutrition and lead exposure was verified before the inspection. Proof of required immunizations for A1 was also verified before the inspection.

LPA discussed the Safe Sleep Regulations with A1 and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA discussed the requirement to check and log infant napping every 15 minutes for infants under 24 months. LPA provided a copy of the LIC 9227, Individual Sleeping Plan, to be completed for infants under 12 months.

LPA also informed A1 of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed with A1. For IMS information, see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.



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SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: XIONG, DAN
FACILITY NUMBER: 344500802
VISIT DATE: 03/29/2023
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication. A1 signed up for PIN’s during the inspection.

A1 was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A1 understands that children’s and staff records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years. LPA reviewed with Licensee the LIC 311D Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. A1 understands that disaster drills must be conducted and documented once every six months.

A1 understands licenses are not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. A1 understands if an unusual incident occurs; Licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance.



A1 understands that if any structural changes are made to the FCCH, Licensing must be notified PRIOR to construction. A1 understands if she wants to make any OFF-limit area an ON-limit area, she must notify Licensing and LPA must do an inspection BEFORE children are allowed in said area. A1 understands annual licensing fees are due on the anniversary of receiving license. The annual fee for a small FCCH is $73.00 per year. A late fee of $36.00 is assessed the day after the anniversary date.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: XIONG, DAN
FACILITY NUMBER: 344500802
VISIT DATE: 03/29/2023
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As of today, 03/29/2023, the license will be pending the proper security of poisons and toxins by lock and key or combination lock. Baby proof latches need to be installed in the bathroom where Clorox wipes, soaps and sanitizer will be stored. The potting soil bag in the backyard needs to be moved to a secure place in the garage out of reach of children. The broken glass observed in the backyard will be removed. The outside door in the backyard, leading to the water heater and gardening tools, needs to be secured with a locking device.

A1 stated she would take care of all the items listed by 04/04/2023. A follow up appointment was set for 04/04/2023 at 8:30 am.


An exit interview was conducted, and the report was reviewed with and given to A1, Dan Xiong, to keep on file at the facility. License Appeal Rights were provided.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Corina Beckby
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4