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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004502
Report Date: 12/06/2024
Date Signed: 12/13/2024 11:11:36 AM

Document Has Been Signed on 12/13/2024 11:11 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:XIAO, YANGFACILITY NUMBER:
414004502
ADMINISTRATOR/
DIRECTOR:		XIAO, YANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 544-8111
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 10DATE:
12/06/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Li LiTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On December 13th, 2024, at approximately 9:30 AM, Licensing Program Analyst (LPA) Janet Gil conducted an unannounced, annual inspection. LPA met with licensee's assistant, Li Li(A1), and explained the purpose of the inspection. Present during LPA’s visit included two assistants, and 10 enrolled children (10 preschoolers). Per A1, licensee is out of town for medical reasons and will return next week. The licensee is a large license and is operating within capacity limits and ratio.

Home consists of 3 bedrooms, 1 bathroom, single level house. Licensee lives in home with spouse. All adults living and working in the home have fingerprint clearance. Facility operates Monday Through Friday 8:00 AM to 6:00 PM.

Day Care Areas: the living room, dining area, bathroom, bedroom #1, bedroom #2, covered patio, backyard, both cabins in backyard and garage (converted to bedroom).

Off Limit Areas: the master bedroom, and kitchen. Off limit area is made inaccessible to children with closed and locked door/gates.

At approximately 10:00 AM, LPA toured day care areas of home with A1. LPA observed the home to be in repair with proper temperature and ventilation. Home is equipped with a variety of toys and materials that were observed to be in working condition. LPA observed a fully stocked accessible first aid kit located in the living room area. LPA did observed accessible cleaning supplies, poisons, and solutions in day care areas. Type B deficiency is being issued on this day in accordance with the California Code of Regulations, Title 22, see LIC 809D. LPA observed electrical outlets to be made inaccessible with outlet covers and furniture. Home is equipped with a fully charged fire extinguisher and a carbon monoxide detector. LPA tested carbon monoxide detector in living room area, which was observed to be working. Licensee does not have any children in care with allergies or IMS plans. Per licensee, parents or authorized representatives provide all foods for the children in care.

At approximately 11:00 AM, LPA observed bathroom for children's use was in proper working condition. LPA observed bathroom to include appropriate toileting equipment and sanitation products.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: XIAO, YANG
FACILITY NUMBER: 414004502
VISIT DATE: 12/06/2024
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The entire backyard is fully enclosed. The outdoor area is equipped with a variety of toys and materials. LPA did not observe any pools, spas, or bodies of water in day care areas. LPA observed two storage units behind home. Per A1 they are off limits for children in care.

LPA reviewed five children records which were complete. The children’s files have a record of emergency identification information and required immunization. LPA reviewed staff records for both assistants which were not fully complete. A1 did not have access to all files and documents. A1's CPR/FIrst Aid is current and will expire 7/2026. A1’s Mandated Reporter training certification is also current and will expire 07/2026. LPA reminded A1 that when licensee is out of facility she must have access to all files and documents in case of an inspection.

Licensee has licensing documentation properly posted and available for review. Per A1, Emergency disaster drills are conducted at least once every six months. LPA reminded A1 she must know where documentation for emergency drills are kept in case of an inspection where licensee is not present. Per A1, there are no weapons or firearms in the home.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: XIAO, YANG
FACILITY NUMBER: 414004502
VISIT DATE: 12/06/2024
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee 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. 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: https://www.ada.gov/resources/child-care-centers/.
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

On this date, 12/12/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

During the exit interview, A1, Li Li, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Type B deficiency is being issued on this day in accordance with the California Code of Regulations, Title 22, see LIC 809D.

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

Exit interview conducted and report was reviewed with the A1, Li Li.
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: Janet Gil
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2024 11:11 AM - It Cannot Be Edited


Created By: Janet Gil On 12/13/2024 at 10:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: XIAO, YANG
FACILITY NUMBER: 414004502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in keeping accesible cleaning supply in bathroom tub and in pass through kitchen area which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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A1 plans to let licensee know to remove all accessible cleaning supplies and email LPA Gil a picture once all cleaning chemicals are removed and place in an inaccessible area.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Garfield Leung
LICENSING EVALUATOR NAME:Janet Gil
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2024


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