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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004502
Report Date: 10/11/2022
Date Signed: 10/17/2022 04:36:04 PM

Document Has Been Signed on 10/17/2022 04:36 PM - 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: 14CENSUS: 10DATE:
10/11/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Yang "CoCo" XiaoTIME COMPLETED:
01:30 PM
NARRATIVE
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On October 11, 2022 at approximately 11:20am, Licensing Program Analyst (LPA) Catrina Quimbo conducted an unannounced, plan of correction (POC) visit. LPA met with licensee's helper, H1, and explained the purpose of the visit. H1 allowed LPA to enter the home. At time of LPA's visit, licensee was not present in the home.

Present during LPA's visit included 10 enrolled children (8 infants and 2 preschool age) and 3 helpers (H1, H2, and H3). LPA called licensee via mobile phone, received licensee's voicemail, left a message and callback number.

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. On June 1, 2022 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 at approximately 1:25pm, LPA Quimbo met with licensee to conduct an unannounced, annual inspection at facility. During annual inspection, LPA observed facility to be operating over capacity with 8 infants (under 24 months) and 2 preschool age (over 24 months). LPA issued a civil penalty for a repeat violation that occurred within 12 months. A POC was developed with licensee. LPA again reviewed infant age and preschool age definitions with licensee.

As of this date, LPA observed the facility to continue to be operating over capacity with 10 enrolled children present, 8 of the children to be infants (under 24 months), and 2 preschool age children (over 24 months). Licensee failed to correct deficiency.
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SUPERVISORS NAME: Cindy Interiano
LICENSING EVALUATOR NAME: Catrina Quimbo
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2022
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: 10/11/2022
NARRATIVE
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At approximately 12:05pm, licensee arrived to facility. LPA explained the purpose of the visit.

LPA observed signed and completed Acknowledgement of Receipt of Licensing Reports (LIC9224) for some of the enrolled children. Licensee provided LPA proof that licensing report dated September 27, 2022 with deficiencies and LIC9224 were sent to all enrolled children's families, however, have not yet been returned to licensee.

Per licensee, enrolled children's families were unable to find alternate care. Licensee stated enrolled families are actively finding alternate care for their children. Per licensee, until alternate care is found, children will continue to attend licensee's home.

Licensee was issued a civil penalty for failure to correct deficiency. See 809D for details.

LPA Quimbo informed licensee, Yang "CoCo" Xiao, that this report dated October 11, 2022 documents 1 Type A citation which shall be posted for 30 consecutive days as there is/are immediate risks to the health, safety, or personal rights of children in care.

Also, LPA Quimbo informed the licensee to provide a copy of this licensing report dated October 11, 2022 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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.

Licensee was also provided appeal rights and procedures.

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: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/17/2022 04:36 PM - It Cannot Be Edited


Created By: Catrina Quimbo On 10/11/2022 at 12:29 PM
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: 10/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2022
Section Cited
CCR
102416.5(d)(1)

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102416.5 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... (1) Twelve children, no more than four of whom may be infants...

This requirement is not met as evidenced by:
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Licensee must reduce the number of children present to be within compliance of a large family child care home license. Civil penalties were assessed for failure to correct deficiency from 09/28/2022 through 10/11/2022 of $100 a day.
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Based on observation, record review and interview, the licensee did not comply with the section cited above. LPA observed 8 infants (under 24 months) and 2 preschool age children to be present in the home, which poses an immediate health, safety or personal rights risk to persons in care.
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Civil penalties will continue to accrue until deficiency is corrected. Office meeting may be conducted.

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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: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2022


LIC809 (FAS) - (06/04)
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