434416353-3-10-2025-07-CC-AYAG-DEMPED-20250310111458

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416353
Report Date: 03/10/2025
Date Signed: 03/10/2025 11:15:32 AM

Document Has Been Signed on 03/10/2025 11:15 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:	ZHOU, XIN		FACILITY NUMBER:	434416353
ADMINISTRATOR/ DIRECTOR:	ZHOU, XIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 990-4564
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95120
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 8	CENSUS: 3	DATE:	03/10/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Xin Zhou		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

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	At 8:30 AM, Licensing Program Analyst (LPA) Andy Yang met with Licensee, Xin Zhou, to conduct an unannounced annual RANDOM inspection. Present for this inspection were Licensee, Husband, (2) Staff, and 3 Children (3 preschool age). All adults living in the home have criminal clearance. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday to Friday 8:15 AM to 5:45 PM. The ages of the children to be served are from 1 to 5 years old. Licensee provided updated application LIC 279 at time of inspection to indicate updated ages to be served, hours of operation, and adults living in the home. The home is single family home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are dining room, kitchen, living room, backyard and bathroom. The OFF LIMIT AREAS are garage, (4) bedrooms, bathroom, master bedroom, master bathroom, and side yard (right side) are inaccessible by closed and/or locked doors and with visual supervision. The ISOLATION AREA is right side of the living room. There are fire arms located in the home. LPA inspected the fire arms which is located in a safe, and the ammo are stored separately in a lock box. The outdoor play area is free from defects or dangerous conditions and is fenced. There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are ample age-appropriate toys that appear to be safe and in good condition. LPA observed the fireplace is barricaded. There are no bodies of water. All hazardous materials and toxins are kept out of the reach of children. Licensee states that any poisons are stored in garage which is OFF LIMITS. LPA reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. *Continue Page 2*

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

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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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: ZHOU, XIN	FACILITY NUMBER: 434416353
	VISIT DATE: 03/10/2025

NARRATIVE

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The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The Licensee CPR and First Aid certificate is current and expires 6/2026. Licensee completed the Mandated Reporter Training for Child Care Providers on 9/24/2023 (expires on 9/2025) and a copy of the certification is on file. Licensee was reminded of Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. The Licensee conducts and documents fire and disaster drills every six months. Last fire drill was conducted on 11/2024. Personnel records are available for review and contain all required forms. Child’s records are available for review and contain all required forms. Licensee has documentation of the 15 minute sleep log in file for infants under 24 months of age. All REQUIRED forms are posted and visible for public review.

Forms of discipline to be used by Licensee are redirecting and talking with the child. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature.

Also, discussed with the Licensee was isolation of sick children, supervision of children, staffing ratio and capacity, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute.

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.
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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

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: ZHOU, XIN	FACILITY NUMBER: 434416353
	VISIT DATE: 03/10/2025

NARRATIVE

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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/.

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.

During the exit interview, the LICENSEE, Xin Zhou, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 2/11/2025.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and
stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other
important information communication platforms.
To receive important licensed related information to licensed facilities, visit the CCLD Important Information
website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child
Care option to receive email communication.

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SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

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: ZHOU, XIN	FACILITY NUMBER: 434416353
	VISIT DATE: 03/10/2025

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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.

No deficiency issued during today's inspection. Appeal Rights provided.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Xin Zhou.

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025

LIC809 (FAS) - (06/04)

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