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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434410267
Report Date: 05/10/2022
Date Signed: 05/10/2022 11:59:01 AM

Document Has Been Signed on 05/10/2022 11:59 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:WANG, XIAOYANFACILITY NUMBER:
434410267
ADMINISTRATOR:WANG, XIAOYANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 386-6128
CITY:MILPITASSTATE: CAZIP CODE:
95035
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
05/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Xiaoyan WangTIME COMPLETED:
12:30 PM
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On Tuesday, May 10, 2022 at 10 am, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced Required 1 Year Visit. LPA met with the Licensee Xiaoyan Wang and explained the nature of site visit. Present on this visit were Licensee's Assistant, Licensee's Spouse and 12 Preschool Children. The home operates from Monday to Friday from 8:30 am to 6:00 pm.

LPA toured the home to conduct a Health and Safety Inspection with the Licensee. The home is a two story home. The On Limit Areas are the Living Room, Day Care Room, Eating Area, Hallway Bathroom, Day Care Room (for napping), Sun Room and the Backyard. The backyard is completely fenced. The OFF-LIMIT AREAS are the entire second floor, the kitchen, and the garage which will be inaccessible to children in care by closed and or locked doors and or a fence with visual supervision. There is a gate located at the bottom of the stairs to prevent access to the second story. The designated isolation area for a child who becomes ill while in care is the Eating Area. 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 present during today's inspection. 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.
The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector and working telephone. The fireplace is screened to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on December 2021. Licensee owns the house and has childcare liability insurance with DCI.

The licensee CPR and First Aid certificate expires on 04/2023. The licensee and Assistant speaks Chinese and will take Mandated Reporter General Training and Child Care Providers training online once it is available on her language


See 809 C......
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Manel Estoesta
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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