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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412281
Report Date: 04/28/2022
Date Signed: 04/29/2022 09:25:48 AM

Document Has Been Signed on 04/29/2022 09:25 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:ZHENG, VERA & XU, BAIRONGFACILITY NUMBER:
434412281
ADMINISTRATOR:ZHENG, VERA & XU, BAIRONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 823-3396
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94043
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 10DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Vera ZhengTIME COMPLETED:
12:30 PM
NARRATIVE
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On 04/28/2022 at 9:30am Licensing Program Analyst (LPA) Christina Uribe, met with licensee Vera "Eva" Zheng for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 10 daycare children and 1 fingerprint cleared co-licensee of home, and the licensee is within ratio today. Upon arrival LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility currently operates 8:00am-6:00pm, Monday-Friday..

The home is a single story home with 3 bedrooms, 1 bathroom, living room, kitchen, garage and back yard. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort.

The OFF-LIMIT AREAS are bedroom #2 & #3, kitchen, & garage and will be inaccessible to children by locked doors, safety gates and visual supervision.

The ON-LIMIT AREAS is the additional bedroom, bathroom, living room, and backyard that is used as the main daycare area. The designated isolation area is in the of the bedroom. The backyard is fully fenced and is in good condition and free from hazardous materials. There is a large shed on the side yard that is inaccessible to children in care.

All hazardous materials and toxins that need to be kept out of reach from children were found to be accessible in the bathroom. LPA Uribe observed unlocked cabinets underneath the bathroom sink which contains cleaning products and cleaning products stored on the floor next to the cabinet. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide, telephone and fully stocked first aid kit. There are no pools, hot tubes or any other bodies of water present at the time of the inspection. Per licensee, there are no firearms on the premises. Facility does have one family dog that is kept away from children in care.

Page 1 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
Document Has Been Signed on 04/29/2022 09:25 AM - It Cannot Be Edited


Created By: Christina Uribe On 04/28/2022 at 11:16 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: ZHENG, VERA & XU, BAIRONG
FACILITY NUMBER: 434412281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

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 as cleaning products were found to be in reach of children in the bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.Licensee immediately removed these items form being accesiblel to children.
POC Due Date: 05/20/2022
Plan of Correction
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Licensee will install child locks on the bathroom cabinet doors and drawers beneath the sink and take a photo and email it to LPA Uribe as proof of correction no later than the due date of 05/20/2022.

Email Address: christina.uribe@dss.ca.gov
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 interview & record review, the licensee did not comply with the section cited above as one of the licensees has not taken the Mandated Reporter Training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Licensee will complete the Mandated Reporter Training for Child Care Providers (AB1207) no later than the due date of 05/20/2022. Licensee will email LPA Uribe a copy of the certifcate of completion by the due date.

Email Address: christina.uribe@dss.ca.gov
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
Page: 8 of 8
Document Has Been Signed on 04/29/2022 09:25 AM - It Cannot Be Edited


Created By: Christina Uribe On 04/28/2022 at 11:16 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: ZHENG, VERA & XU, BAIRONG
FACILITY NUMBER: 434412281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as both licensees do not have proof of immunization for Tdap (Pertussis) and does not have record of TB clearance. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Licensees will provide proof of immunization record for Tdap (Pertussis) and a TB Clearance and email the forms to LPA Uribe no later than the due date of 05/20/2022.

Email Address: christina.uribe@dss.ca.gov
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as multiple children's files have incomplete or missing Identification & Emergency (LIC 700) forms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Licensee will have each parent fill out the entire Identification & Emergency (LIC 700) form and email proof for each child to LPA Uribe no later than the due date of 05/20/2022.

Email Address: christina.uribe@dss.ca.gov
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 04/29/2022 09:25 AM - It Cannot Be Edited


Created By: Christina Uribe On 04/28/2022 at 11:16 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: ZHENG, VERA & XU, BAIRONG
FACILITY NUMBER: 434412281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as 3 children's records were missing proof of immunization records. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/20/2022
Plan of Correction
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Licensees will obtain proof of immunization record for each child and email the forms to LPA Uribe no later than the due date of 05/20/2022.

Email Address: christina.uribe@dss.ca.gov
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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ZHENG, VERA & XU, BAIRONG
FACILITY NUMBER: 434412281
VISIT DATE: 04/28/2022
NARRATIVE
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The licensee conducts and documents fire and disaster drills at least every six months and the last conducted drill was on 04/21/2022. All required forms are posted and visible for public review.

Personnel Records: The licensee's CPR/First Aid certification expires on 01/08/2024 and Mandated Reporter Certification expires on 04/01/2024. Co-licensee does not have a current Mandated Reporter Training Certificate and has not completed the training. Both licensees do not have current proof of immunization records for Tdap (Pertussis) nor do they have proof of a TB clearance.



Childrens Records: Childrens records were reviewed by LPA Uribe at 10:00am. It was observed through record review that 3 children did not have proof of immunizations and 7 children had an incomplete or missing Identification and Emergency (LIC 700) form. Individual Infant Safe Sleep Plans are not required as the facility does not have children under the age of 12 months in care at this time. Sleep Charts for sleeping infants were not available for review for the one child in care that is younger than 24 months of age. There is a current roster available for review and licensee was instructed to include the first and last name of both the children and parents on this form. The facility does have liability insurance at this time. Staff interview also conducted and documented.

Incidental Medical Services (IMS) policy was discussed and the facility does not have any children with the need for medication to be kept at the facility at this time. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Page 2 of 3 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: ZHENG, VERA & XU, BAIRONG
FACILITY NUMBER: 434412281
VISIT DATE: 04/28/2022
NARRATIVE
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LPA 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-and-resources/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.

Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

Deficiencies Cited During Today's Inspection: See attached deficiency pages and advisory notes

  • Type B Violation: Cleaning products not properly stored and were easily accessible to children in care.
  • Type B Violation: Co-licensee has not completed the Mandated Reporter Training.
  • Type B Violation: Both licensees do not have proof of immunization for Tdap (Pertussis) and does not have record of TB clearance.
  • Type B Violation: Incomplete Identification and Emergency (LIC 700) forms. 3 children's LIC 700 need parent signature & date. 2 children's LIC 700 need the physician/dentist information and parent signature. 2 children's did not have an LIC 700 on file.
  • Type B Violation: 3 children's records were missing proof of immunization records.
  • Technical Violation: One child in care is 22 months of age and licensees do not have documentation of the 15-minute checks on a sleep log.
  • Technical Violation: Personnel records for both licensees are not maintained nor available for review.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Vera "Eva" Zheng.

Page 3 of 3 ***Report Complete***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC809 (FAS) - (06/04)
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