<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416353
Report Date: 01/26/2023
Date Signed: 01/26/2023 12:11:15 PM

Document Has Been Signed on 01/26/2023 12:11 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ZHOU, XINFACILITY NUMBER:
434416353
ADMINISTRATOR:ZHOU, XINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 990-4564
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 9DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Xin ZhouTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Janette Cruz and Ashley Lopez met with Xin Zhou, Licensee, for an unannounced Required – 1 year annual inspection. LPAs were granted access to the home by the Licensee. LPAs also observed Licensee's spouse, Han Zhang, Licensee's adult assistant, Wanmei Zeng, five preschool children and four infants present in the home during today's inspection. LPAs observed the required postings, including the facility license by the front door area of the home. Days and hours of operations are Monday - Friday from 8:00AM to 6:00 PM. The Licensee and the Licensee's spouse are the only adults residing in the home. Licensee has current CPR and First Aid certifications (expiration: 10/08/2024).

LPAs reviewed the Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 07/22/22. Licensee has an active Child Care Liability Insurance (valid 03/31/23) . Licensee has the required vaccinations (MMR, Tdap, & flu). LPAs reviewed Licensee's record of Mandated Reporter Training credential (valid 02/24/24). LPAs reviewed five children's files which were complete with the required forms.

LPAs discussed the safe sleep regulations with the 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. LPAs also informed the 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.

LPAs toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home, (415) 990-4564. LPAs observed sufficient materials, toys, and play equipment for the day care children. Licensee states that a child

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ZHOU, XIN
FACILITY NUMBER: 434416353
VISIT DATE: 01/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
will be isolated in the living room area of the home if necessary due to illness or communicable disease.

LPAs observed the home is clean, orderly, and safe for the day care children. LPAs observed a barricaded fireplace and no open face heaters in the home. LPAs observed a fenced backyard. Off limit areas inside the home : Master bedroom with bathroom and three bedrooms,

Off limit areas outside the home are as follows: gated right side of the home.

LPAs observed a fully charged 3A40BC fire extinguisher and working smoke/carbon monoxide detectors. LPAs observed that Licensee does not have pets in the home. LPAs observed a pistol and a shot gun stored in a locked safe box, and ammunition stored separately in another locked safe box inside the larger safe box. All other detergents, cleaning compounds, medications, and similar items are inaccessible to children. All poisons are stored in the garage. The Licensee states that she administers medication to the day care children at this time.

This facility provides Incidental Medical Services – IMS. LPAs reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

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.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: ZHOU, XIN
FACILITY NUMBER: 434416353
VISIT DATE: 01/26/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Supervision of children was discussed with Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options that she cannot have more than 14 children in the home at any time without an adult assistant. Licensee states that she does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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.


Exit interview conducted and report was reviewed with the Licensee, Xin Zhou. No deficiency was issued during today's inspection.

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

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3