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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004502
Report Date: 11/08/2022
Date Signed: 11/08/2022 11:44:19 AM

Document Has Been Signed on 11/08/2022 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:XIAO, YANGFACILITY NUMBER:
414004502
ADMINISTRATOR:XIAO, YANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 544-8111
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 5CENSUS: 3DATE:
11/08/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Yang "CoCo" XiaoTIME COMPLETED:
12:00 PM
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On November 8, 2022 at approximately 10:40am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, plan of correction (POC) visit. LPA met with licensee, Yang "CoCo" Xiao, and explained the purpose of the visit.

Present during LPA's visit included licensee, licensee's two helpers (H1 and H2) and 3 enrolled children (3 infants).

On April 1, 2022, department received a complaint allegation that facility was operating beyond licensing capacity limits and ratio. LPA conducted a complaint investigation and found licensee to be operating at a time (February 2022) over capacity with 5 infants. Licensee was issued a Type B citation. A POC was developed with licensee. LPA reviewed infant age and preschool age definitions with licensee. During complaint investigation, licensee operated within capacity limits and ratio. Deficiency was cleared.

On September 27, 2022, LPA conducted an unannounced, annual inspection at facility. During annual inspection, LPA observed licensee to be operating over capacity with 8 infants (under 24 months) and 2 preschool age (over 24 months). LPA issued a civil penalty for repeat violation that occurred within 12 months. A POC was developed with licensee. LPA again reviewed infant age and preschool age definitions with licensee.

On October 11, 2022 LPA conducted a POC visit at facility, to verify licensee corrected deficiency. LPA observed licensee to continue to be operating over capacity with 10 enrolled children (8 infants and 2 preschool age). LPA issued a civil penalty for repeat violation that occurred within 12 months. A POC was developed.

As of this date, Licensee has lowered overall enrollment at facility. Licensee stated they have 5 enrolled children (all infants). Present during LPA's visit included 3 infants.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: XIAO, YANG
FACILITY NUMBER: 414004502
VISIT DATE: 11/08/2022
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Licensee stated children's schedules are staggered as to not exceed 4 infants at a time. LPA reminded licensee in family child care home, an infant is defined as under 24 months. Licensee stated they understood.

Licensee stated previously enrolled children found alternate care. Per licensee, children may reenter licensee's program once they are over 24 months.

LPA observed signed and completed Acknowledgement of Receipt of Licensing Reports (LIC9224) for the enrolled children. LIC9224s were observed to be dated and signed by children's authorized representatives. LPA reminded licensee LIC9224 must be provided to all newly enrolled children's authorized representatives for up to 1 year. Licensee stated they understood.

LPA reminded licensee they may be brought into office for an office meeting with LPA and Licensing Program Manager (LPM). Licensee stated they understood.

Deficiencies cited on 10/11/2022 has been cleared as of this date.

No deficiencies were cited today under CCR, Title 22, Div. 12.

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.

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

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC809 (FAS) - (06/04)
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