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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434412837
Report Date: 01/09/2025
Date Signed: 01/14/2025 09:48:58 AM

Document Has Been Signed on 01/14/2025 09:48 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:LUN, XIAOQINGFACILITY NUMBER:
434412837
ADMINISTRATOR/
DIRECTOR:		LUN, XIAOQINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 898-4407
CITY:SUNNYVALESTATE: CAZIP CODE:
94089
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 7DATE:
01/09/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:48 PM
MET WITH:XiaoQing LunTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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Licensing Program Analyst (LPA), Shine Yu, conducted an unannounced Annual Inspection and arrived at 2:48 pm. Present are licensee, one employee and 7 children who are taking nap time. Licensee stated she has one tenant.

LPA observed the following materials posted on the bulletin board, including the Facility License, Notification of Parents' Rights (PUB 393) and Fire Drill check log. The last fire drill conducted was 10/15//2024. Facility's operating hours are Monday to Friday 8:30AM to 6PM. All children enrolled are full time and LPA took a photo of current Children's roster.

LPA reviewed 5 children's files and observed that notification of parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification forms are in each file. LPA also reviewed the staff files for the following records: LIC 9052 Employee Rights, the Immunization Record showing immunity to measles (MMR), pertussis (Tdap). Licensee's pediatric First Aid & CPR expires on Sep, 2026. Employee Wang's pediatric 1st Aid & CPR expires 9/7/2026.

LPA toured the facility with licensee. Licensee keep the bathroom is clean. There is smoke detector and carbon monoxide detector in dinning area by the kitchen. There are plenty of age appropriate toys for children both in living room and out door play area. Licensee stated there is no firearm in the facility. There are two wall heaters in the hallway, both are barricaded properly and hallway is barricaded by gate. There is no body of water observed outside of play yard. The outdoor play area is enclosed with fence and safe for children.

Continue on next page, LIC 809C

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2025
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 3
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: LUN, XIAOQING
FACILITY NUMBER: 434412837
VISIT DATE: 01/09/2025
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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.

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-andresources/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.

Licensee stated there is no medication provided in the facility. 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/.

LPA encouraged the Licensee to frequently visit our website at www.ccld.ca.gov for licensing regulations and new updates. The Licensee can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

Continue on next page, LIC 809C.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
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: LUN, XIAOQING
FACILITY NUMBER: 434412837
VISIT DATE: 01/09/2025
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The 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.

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.

Exit interview conducted and report was reviewed with licensee, XiaoQing Lun.

the licensee also confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



No deficiency cited for today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days

The report was discussed and verbally translated into Mandarin during the exit interview with Licensee, XiaoQing Lun.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Syhshyan Yu
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2025
LIC809 (FAS) - (06/04)
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