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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434416452
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:13:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/03/2021 and conducted by Evaluator Yangcheng Huang
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20211203142153
FACILITY NAME:XIN, GUOYINGFACILITY NUMBER:
434416452
ADMINISTRATOR:GUOYING XINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 899-4933
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:14CENSUS: 6DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Guoying XinTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
PPE is not being worn on the facility grounds
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Oscar Huang made a 10-day initial complaint investigation to the facility. LPA met with Licensee, Guoying Xin, and discussed the above allegation with her. LPA also observed 1 staff and 6 children (4 infants & 2 preschoolers). LPA interviewed licensee, and copies of pertinent documents were also obtained.

Based on interview of Licensee and LPA's own observations for the complaint allegation listed above. LPA concludes that the preponderance of evidence standard has been met and the allegation listed above is therefore SUBSTANTIATED. Advisory Note -Technical Assistance is being issued on the attached LIC 9102.

Exit interview conducted with Licensee, Guoying Xin.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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