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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004502
Report Date: 04/06/2022
Date Signed: 04/06/2022 11:22:28 AM

Document Has Been Signed on 04/06/2022 11:22 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: 10CENSUS: 9DATE:
04/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Yang XiaoTIME COMPLETED:
11:15 AM
NARRATIVE
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On April 6, 2022 at 9:15am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, complaint investigation with a case management inspection to Yang Xiao Family Child Care Home. LPA met with licensee, Yang Xiao and explained the purpose of the inspection.

During the visit, LPA inspected day care areas for health and safety hazards. Present during the visit included licensee, licensee's spouse, 9 enrolled children (1 infant and 8 preschool age), A1, and A2. LPA observed A1 and A2 directly working with and supervising the enrolled children in care.

At approximately 9:30am, A3 arrived to facility. At approximately 9:35am, LPA requested proof of A1 and A2's fingerprint clearance.

Licensee provided LPA proof A1 is exempt from fingerprint clearance due to being a volunteer providing time limited specialized services. LPA reminded licensee a volunteer can not exceed 16 hours a week in the facility, must be directly supervised by licensee or facility employee with current criminal record clearance, and is never left alone with the children.

Licensee could not provide LPA proof of A2's fingerprint clearance. Per licensee, A2 did not complete live scan process. During LPA's visit, LPA observed A2, an uncleared employee, directly working with and supervising enrolled children in care. This poses an immediate health and safety risk to children in care.

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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: XIAO, YANG
FACILITY NUMBER: 414004502
VISIT DATE: 04/06/2022
NARRATIVE
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(Continued, Page 2...)

At approximately 10:00am, A2 left facility to begin fingerprint clearance process. LPA informed licensee A2 is not to return to work at facility until A2 receives fingerprint clearance. Licensee stated she understood.

Licensee was issued a Type A citation for an uncleared fingerprint adult directly working with the children. Please refer to 809D for more information.

After today's visit, an exit interview was conducted with licensee, Yang Xiao. This report is public and can be reviewed. A copy of this report along with appeal rights and procedures and notice of site visit will be emailed to licensee info@magieducation.org.

Licensee was reminded that the notice of site visit shall be posted in a prominent place in facility for 30 days during the hours of operation. Failure to maintain postings as required will result in a civil penalty of $100.
SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/06/2022 11:22 AM - It Cannot Be Edited


Created By: Catrina Quimbo On 04/06/2022 at 10:33 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: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/06/2022
Section Cited
CCR
102370(d)(1)

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102370 Criminal Record Clearance (d)(1) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.

This requirement was not met as evidenced by:
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A2 left facility during LPA's visit. A2 will not return to work at facility until fingerprint clearance is received.
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Based on observation, interviews and record review, A2, an uncleared individual directly working with supervising enrolled children. This poses an immediate Health and Safety risk to persons in care.
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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:Cindy Interiano
LICENSING EVALUATOR NAME:Catrina Quimbo
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


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