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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416822
Report Date: 08/26/2024
Date Signed: 08/26/2024 05:33:41 PM

Document Has Been Signed on 08/26/2024 05:33 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:YANG, SIYAOFACILITY NUMBER:
434416822
ADMINISTRATOR/
DIRECTOR:		SIYAO, YANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 619-0812
CITY:CUPERTINOSTATE: CAZIP CODE:
95014
CAPACITY: 12TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
08/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:40 PM
MET WITH:Yang SiyaoTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Marilou Monico conducted a Case Management inspection. LPA met with Licensee, Siyao Yang. Also present in the home were three adult helpers (S1, S2, & S3) and eight (8) daycare children: 3 infants and 5 preschool age. Based on record review, the two adult helpers (S1 & S2) have fingerprint clearances, however their clearances are not associated to the facility. Licensee states that S1 & S2 have been working at the facility for more than five (5) days.

As a result of this inspection, Type A deficiency is cited on the following page.

Assembly Bill (AB) 633 was provided and discussed with Licensee. LPA informed Licensee to provide a copy of this licensing report dated 08/26/24 that documents a Type A citation to parents/guardians of all children currently enrolled no later than the next business day or the next day the children are in care, and to parents/guardians of any newly enrolled children for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC9224) must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with Licensee, Siyao Yang.

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: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2024
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 11/06/2024 02:23 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/05/2024 04:58 PM


Created By: Marilou Monico On 08/26/2024 at 04:55 PM
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: YANG, SIYAO
FACILITY NUMBER: 434416822

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
08/27/2024
Section Cited
CCR
102370(d)(2)

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Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 102370(j) .
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By POC due date: 08/27/24, Licensee states she will submit written plan to ensure that S1 & S2 are associated to the facility by submitting Criminal Background Transfer Request (LIC 9182) to Licensing or associate S1 & S2 through Guardian.
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This requirement is not met as evidenced by:
Based on record review, S1 & S2 have fingerprint clearances, however their clearances are not associated to the facility. This poses an potential risk to the health, safety, and personal rights to children in care.
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Civil penalty of $1000 was assessed.

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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: 08/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024


LIC809 (FAS) - (06/04)
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