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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412281
Report Date: 04/28/2022
Date Signed: 04/28/2022 01:04:35 PM

Document Has Been Signed on 04/28/2022 01:04 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, 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Vera ZhengTIME COMPLETED:
01:30 PM
NARRATIVE
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On 04/28/22 at 12:30pm, Licensing Program Analyst (LPA) Christina Uribe conducted an unannounced visit for the purpose of investigating a complaint and met with licensee, Vera “Eva” Zheng. Also present during today’s visit is co-licensee Bairong “Vivi” Xu and 10 children.

During the course of the complaint investigation, it was found that the licensee was aware of the fact that a child who was injured in the facility’s care received medical treatment as a result of the injury. The child was taken to urgent care by their parent the same day as the incident occurred and had an appointment with a specialist the following day. Once the licensee was aware that the child needed medical treatment, the licensee should have reported the incident to Community Care Licensing by phone within 24 hours and a written statement using the Unusual Incident/Injury Report (LIC 624) form.

The licensee failed to report the injury as required resulting in a Type B violation. Refer to LIC809D for additional information.

A note 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. Exit interview conducted and report was reviewed with the licensee, Vera “Eva” Zheng.

Page 1 of 1 ***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
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 2
Document Has Been Signed on 04/28/2022 01:04 PM - It Cannot Be Edited


Created By: Christina Uribe On 04/28/2022 at 12:45 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
, 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
HSC
1597.467(b)(1)

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Health & Safety Code, Section 1597.467(b)(1): A report shall be made to the department by telephone or fax during the department’s normal business hours before the close of the next working day following the occurrence during the operation of a family child care home of any of the following incidents:
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Licensees will watch the “Child Care Reporting Requirements” training video on our website at ccld.childcarevideos.org. Licensees will also refer to the Unusual Incident/Injury Report (LIC 624B) forms and carefully read both pages.Both licensees will mail LPA Uribe an original signed letter stating that they have watched the training video, read the LIC624B
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(B) Any injury to any child that requires medical treatment.This requirement is not met as evidenced by: a child required medical treatment due to an injury sustained while in care was not reported to the Department, which poses a potential health, safety, or personal rights risk to persons in care.
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forms, and understand their responsibility for reporting unusual incidents or injuries to the Department. This letter of acknowledgement must be signed by each licensee and mailed to 1515 Clay Street, Suite 1102, Oakland, Ca 94612 no later than the due date of 05/20/22.

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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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