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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 384004326
Report Date: 08/06/2021
Date Signed: 08/06/2021 09:55:49 AM

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
06/10/2021 and conducted by Evaluator Winnie Ly
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20210610094339
FACILITY NAME:XU, YINGFEIFACILITY NUMBER:
384004326
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 4DATE:
08/06/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:YingFei XuTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is operating over capacity.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On August 6, 2021 at approximately 9:30am, Licensing Program Analyst (LPA) Ly arrived at facility and met with Licensee YingFei Xu to close this complaint. The purpose of the inspection was explained. Present during the visit were licensee and her husband acting as day care assistant caring for 3 infants and 1 toddler.

During the course of investigation, LPA inspected the facility, reviewed records, conducted interviews, and obtained copies of pertinent documents. Based on information gathered, although the allegation Facility is Operating Over Capacity may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed UNSUBSTANTIATED.

An Exit Interview was conducted with Licensee. No deficiencies were issued today under Title 22 Division 12 of the California Code of Regulations. A copy of this report and notice of site visit were discussed and left with Licensee whose signature on this form confirm receipt of these reports. Notice of Site Visit was posted. Notice to remain posted for 30 days. For updates on Licensing information, go to CCL website: www.ccld.ca.gov. For Provider Information Notice: ccld.ca.gov/PG5098.htm
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Winnie Ly
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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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