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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412281
Report Date: 05/27/2022
Date Signed: 05/27/2022 10:32:16 AM

Document Has Been Signed on 05/27/2022 10:32 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: 12CENSUS: 8DATE:
05/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Vera ZhengTIME COMPLETED:
10:45 AM
NARRATIVE
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On 05/27/2022 at 9:30am, Licensing Program Analyst (LPA) Christina Uribe conducted an unannounced Case Management visit and met with licensee, Vera “Eva” Zheng. Also present during today’s inspection is co-licensee Bairong “Vivi” Xu and 8 daycare children. The purpose of today’s visit is to verify if a required correction for a previously cited violation had been met.

On 04/28/2022, LPA Uribe conducted an annual inspection at the facility and a Type B Violation was cited for both licensees not having record of a TB clearance or proof of Tdap (Pertussis) immunization. The Plan of Correction (POC) was created and required that proof of a TB clearance and immunization for Tdap (Pertussis) for both licensees be provided to LPA Uribe no later than the POC due date on 05/20/2022. Only Eva's TB Clearance has been corrected but not her proof of immunization for Tdap (Pertussis) and Vivi's TB Clearance and proof of immunization of Tdap (Pertussis) was not completed either. As of today’s visit, the POC has not been met and the facility is in violation of failure to correct the deficiency which results in an additional Type B Violation being cited today. Please see LIC 809D for additional deficiency information and plan of correction due date.

Notice of site visit was given and must remain posted for 30 days. Appeal rights were given and exit interview was conducted with licensee, Vera “Eva” Zheng.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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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Document Has Been Signed on 05/27/2022 10:32 AM - It Cannot Be Edited


Created By: Christina Uribe On 05/27/2022 at 10:19 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: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
HSC
1597.622(c)

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HSC 1597.622(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunizations, 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 me as evidenced by:
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This deficiency has been previously cited and is being issued today due to failure to correct the plan of correction issued on 04/28/2022. TB Clearance and proof of Tdap (Pertussis) needed for VIivi. Proof of Tdap (Pertussis) needed for Eva.
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Based on record review & interview, the licensee did not comply with the section cited above as both licensees do not have proof of immunization for Tdap (Pertussis) and one licensee does not have record of TB clearance, which poses a potential health, safety, or personal rights risk to persons in care.
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Licensees will provide proof of immunization record for Tdap (Pertussis) for both of them and TB clearance for Vivi only and email the forms to LPA Uribe no later than the due date of 06/10/2022.

Email Address: christina.uribe@dss.ca.gov

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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: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022


LIC809 (FAS) - (06/04)
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