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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384004022
Report Date: 03/08/2022
Date Signed: 03/08/2022 05:44:09 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/10/2022 and conducted by Evaluator Jennifer Yee
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20220210085436
FACILITY NAME:LI,XIAO YANFACILITY NUMBER:
384004022
ADMINISTRATOR:LI,XIAO YANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 272-9286
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY:14CENSUS: 9DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Xiao Yan LiTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Provider leaves the room during nap times.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst, LPA Yee met with Licensee, Xiao Yan Li aka Angel to close this complaint. The purpose of the inspection was explained. There are 9 children present today. During the course of the investigation, LPA interviewed Reporting Party, the Licensee, 3 children, two parents and a roster.


Based on the information gathered, it cannot be proven or disproven regarding any violations of the above allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are "unsubstantiated".

This report is reviewed with Licensee and a copy of this report must be made available for public review upon request.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Jennifer Yee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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