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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 414004502
Report Date: 06/01/2022
Date Signed: 06/01/2022 01:41:08 PM

Substantiated


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
04/01/2022 and conducted by Evaluator Catrina Quimbo
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20220401103343
FACILITY NAME:XIAO, YANGFACILITY NUMBER:
414004502
ADMINISTRATOR:XIAO, YANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 544-8111
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:14CENSUS: 12DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Yang XiaoTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Facility operates out of capacity.
INVESTIGATION FINDINGS:
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On June 1, 2022 at approximately 11:30am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, complaint investigation to Yang Xiao Family Child Care Home. LPA met with licensee, Yang Xiao, and explained the purpose of the inspection. Present during visit included licensee, licensee's helper (h1), and 12 enrolled children (4 infants and 8 preschool age).

During investigation, LPA conducted facility observations, interviews and reviewed records and documents. Random selection of individuals interviewed, stated in the month of February 2022, facility operated with more than 4 infants at one time. Child care roster LPA obtained from licensee showed at least 5 infants to have been enrolled during the month of February 2022. During LPA's interview with licensee, Yang Xiao, conducted on 06/01/2022, licensee stated in the month of February 2022, all enrolled children attended licensee's home full time. Licensee stated they believed children under 12 months were infants while children between 13 months to 18 months were toddler age. In February 2022 , facility operated with more than 4 infants at one time. Licensee operated beyond capacity limits and ratio of a large license.

(Continue on Page 2...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
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 5
Control Number 05-CC-20220401103343
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: XIAO, YANG
FACILITY NUMBER: 414004502
VISIT DATE: 06/01/2022
NARRATIVE
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(Continued, Page 2...)

Based on LPA’s interviews and record review which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 12, Chapter 1, are being cited. Please refer to 9099D for more information.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

A copy of this report was emailed to licensee with Appeal Rights and Procedures.

Exit interview conducted and report was reviewed with licensee, Yang Xiao.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 05-CC-20220401103343
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: XIAO, YANG
FACILITY NUMBER: 414004502
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2022
Section Cited
CCR
102416.5(d)(1)
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102416.6 Staffing Ratio and Capacity (d)(1) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time...shall be...Twelve children, no more than four of whom may be infants.
This requirement was not met as evidenced by:
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LPA and licensee discussed the large license capacity ratio and requirements. LPA explained definition of infants to be under 24 months, and preschool age to be over 24 months. LPA explained no Family Child Care Home Provider shall operate at any time with more than 4 infants.
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Based on interviews and record review, the licensee did not comply with the section cited above in number of infants present in facility in February 2022, which poses a potential health, safety or personal rights risk to persons in care.
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During LPA's visits to the home on 04/06/2022 and 06/01/2022, LPA observed licensee to be operating within capacity ratio and requirements. Licensee stated she understands Family Child Care Home definitions. Deficiency cleared during visit.
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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: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
04/01/2022 and conducted by Evaluator Catrina Quimbo
PUBLIC
COMPLAINT CONTROL NUMBER: 05-CC-20220401103343

FACILITY NAME:XIAO, YANGFACILITY NUMBER:
414004502
ADMINISTRATOR:XIAO, YANGFACILITY TYPE:
810
ADDRESS:2314 S. NORFOLK STREETTELEPHONE:
(650) 544-8111
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:13CENSUS: 12DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Yang XiaoTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff handles child in a rough manner.
Staff reports false information to responsible parties.
Staff do not properly supervise daycare children.
Staff not maintained free of hazardous items.
Staff misuse children's personal item.
Facility not maintained clean and orderly.
INVESTIGATION FINDINGS:
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On June 1, 2022 at approximately 11:30am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, complaint investigation to Yang Xiao Family Child Care Home. LPA met with licensee, Yang Xiao, and explained the purpose of the inspection. Present during visit included licensee, licensee's helper (h1), and 12 enrolled children (4 infants and 8 preschool age).

During investigation, LPA conducted facility observations, interviews and reviewed records and documents to investigate above allegations. Random selection of individuals related to facility and random selection of parents whose children attend facility, stated staff handle children with care, staff do not report false information, children are properly supervised, staff do not use children's personal items and facility is maintained clean and orderly and is free of hazardous materials.

During LPA's visits to home on 04/06/2022 and 06/01/2022, LPA did not observe any hazardous materials or items and observed home to be clean and orderly.

(Continue Report on Page 2...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 05-CC-20220401103343
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: XIAO, YANG
FACILITY NUMBER: 414004502
VISIT DATE: 06/01/2022
NARRATIVE
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(Continued, Page 2...)

Although the above allegation may have happened or is valid, based on LPA's observations, interviews and record review which were conducted, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

A notice of site visit was given and must remain posted for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

A copy of this report was emailed to licensee with Appeal Rights and Procedures.

Exit interview conducted and report was reviewed with licensee, Yang Xiao.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5