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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416716
Report Date: 12/11/2024
Date Signed: 12/11/2024 11:34:32 AM

Document Has Been Signed on 12/11/2024 11:34 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:ZHANG, SIJIAFACILITY NUMBER:
434416716
ADMINISTRATOR/
DIRECTOR:		ZHANG, SIJIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 981-4915
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 14TOTAL ENROLLED CHILDREN: 10CENSUS: 7DATE:
12/11/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Sijia ZhangTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Marilou Monico and Andy Yang conducted a Case Management Inspection. LPAs learned from interviews that unusual incidents occurred in the home on 11/22/24 and 12/02/24 involving a daycare child (C1) were not reported to Licensing.

As a result, deficiency was cited on the following page.

Exit interview conducted and the report was reviewed with Licensee, Sijia Zhang.

A Notice of Site Visit was issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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 12/11/2024 11:34 AM - It Cannot Be Edited


Created By: Marilou Monico On 12/11/2024 at 10:58 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: ZHANG, SIJIA
FACILITY NUMBER: 434416716

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/13/2024
Section Cited
CCR
102416.2(b)

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Reporting Requirements - The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home.
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Licensee states that she will submit a written plan to Licensing by 12/13/24 to ensure that unusual incidents must be reported to Licensing within the required time frame,
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This requirement was not met as evidenced by: The licensee failed to report unusual incidents to Licensing. This poses a potential risk to the health, safety, and personal rights to children in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Marilou Monico
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2024


LIC809 (FAS) - (06/04)
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