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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416348
Report Date: 03/20/2024
Date Signed: 03/20/2024 10:10:53 AM

Document Has Been Signed on 03/20/2024 10:10 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:BAI, XIAOFACILITY NUMBER:
434416348
ADMINISTRATOR:BAI, XIAOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 888-1302
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 10DATE:
03/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Xiao BaiTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang met with licensee, Xiao Bai for an unannounced case management visit. LPA explained the nature of today’s inspection to licensee.

The San Jose Regional Office received notice of a fire and an arrest occurred at the facility on Sunday, 3/10/2024 from other government agencies. The facility was not in compliance with Title 22 regulation & Health and Safety Code in reporting requirements for failure to report the fire and the arrest within 24 hours/next business day, which was Monday 03/11/2024.

According to AB 633, all parents of children currently enrolled and any future children being enrolled for the next 12 months must be provided with this report which contains this type A deficiency.

A type "A" deficiency was cited. A notice of site visit was given and must remain posted for 30 days. The report was discussed and verbally translated into Chinese during the exit interview with Licensee, Xiao Bai.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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 03/20/2024 10:10 AM - It Cannot Be Edited


Created By: Yangcheng Huang On 03/20/2024 at 08:20 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: BAI, XIAO
FACILITY NUMBER: 434416348

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2024
Section Cited
CCR
102416.2(c)(2)

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Reporting Requirements: (c) In addition to the events specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C), the licensee shall report the following events to the Department:
(2) Fires or explosions occurring in or on the premises of the family child care home.
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Plan of Correction along with Unusual Incident Report (LIC 624B) are required to submit to the office in written indicating methods and procedures implemented to ensure the facility stays in compliance with Tittle 22 in reporting requirements to ensure this will not occur going forward.
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This requirement was not met as evidenced by: Licensee did not report the fire and the arrest that occurred in the family day care home on Sunday, 03/10/2024, to the licensing agency within the next business day. This posed an immediate safety & health risk to children in care.
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According to AB 633, all parents of children currently enrolled and any future children being enrolled for the next 12 months must be provided with this report which contains this type A deficiency.

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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024


LIC809 (FAS) - (06/04)
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