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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 430751096
Report Date: 10/11/2024
Date Signed: 10/11/2024 10:40:43 AM

Document Has Been Signed on 10/11/2024 10:40 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:CASEY, XUAN & PATRICKFACILITY NUMBER:
430751096
ADMINISTRATOR/
DIRECTOR:		CASEY, XUANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 881-3088
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
10/11/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Xuan CaseyTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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At 8:25 AM, Licensing Program Analysts (LPAs) Andy Yang and Mandeep Kaur met with Licensee, Xuan Casey to conduct an unannounced 3-YEAR REQUIRED inspection. Present for this inspection was Licensee, Assistant, 4 Children (3 Infants, and 1 Preschool age). Licensee has 4 children enrolled. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday to Friday 6:00 AM to 6:00 PM.

The home is Single Family Home. The home consists of Living room, Kitchen, Playroom, Office, 2 Bedrooms, Bathroom, Master Bedroom, Master Bathroom, Backyard, and Garage. The home has heating and ventilation for safety and comfort. LPAs reminded that home shall be kept clean and orderly. The ON LIMIT AREAS are Kitchen, Living room, Playroom, and Bathroom, and Backyard. The OFF LIMIT AREAS are Living room, Office, Garage, 2 Bedrooms, Master Bedroom, and Master Bathroom which will be inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA is the Playroom . The outdoor play area is free from defects or dangerous conditions and is fenced. There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are ample age-appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs, or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children, and it was observed that there are no toxins or hazardous items accessible today. Licensee states that any poisons are stored in the Garage which is OFF LIMITS. LPAs reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes.

The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The Licensee CPR and First Aid certificate is current and expires 4/23/2025. Licensee completed the Mandated Reporter Training for Child Care Providers on 10/21/2023 and a copy of the certification is on file. Licensee was reminded of Mandated reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. Per Licensee, there are no firearms in the home. The Licensee conducts and documents fire and disaster drills every six months. Personnel records are available for review and contain all required forms. Child’s records are available for review and contain all required forms. All REQUIRED forms are posted and visible for public review.
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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/11/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CASEY, XUAN & PATRICK
FACILITY NUMBER: 430751096
VISIT DATE: 10/11/2024
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LPs discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPAs 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 child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, Xuan Casey, confirmed that there are no Registered Sex Offenders living in the facility and LPA Yang completed the RSO profile in FAS. Megan's Law was checked on 09/19/2024.

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.


During today’s inspection, a “Type B” deficiency is issued on attached 809-D. Appeal rights provided.

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

Exit interview conducted and report was reviewed with the Licensee, Xuan Casey.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/11/2024 10:40 AM - It Cannot Be Edited


Created By: Andy Yang On 10/11/2024 at 09:54 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: CASEY, XUAN & PATRICK
FACILITY NUMBER: 430751096

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Assistants's record review, the licensee did not comply with the section cited above, which
poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2024
Plan of Correction
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By POC date: 10/18/2024, the Licensee will submit the Assistant's certificate of completion of the Mandated Reporter Training (AB1207).
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:Belinda Devall
LICENSING EVALUATOR NAME:Andy Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2024


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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: CASEY, XUAN & PATRICK
FACILITY NUMBER: 430751096
VISIT DATE: 10/11/2024
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All cribs or play yards meet the safety standards. The cribs or play yards do not hinder entrance or exit to and from the space where infants are sleeping. The mattresses in the crib or play yards are firm and covered with a fitted sheet that is appropriate, fits tightly, and overlaps the underside of the mattresses. Each infant’s bedding is used for them only and cleaned weekly or before use by another infant. There are no loose articles and objects, bumper guards or objects hanging above or attached to the side of the cribs or play yards. Each infant under 12 months of age has an Individual Infant Sleeping Plan maintained in the file signed and dated, including the infant’s sleeping position and documentation of 15 minute checks while sleeping.

Forms of discipline to be used by Licensee are redirecting and talking with the child. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature.

Also, discussed with the Licensee was isolation of sick children, supervision of children, staffing ratio and capacity, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute.

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: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024
LIC809 (FAS) - (06/04)
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