434417571-8-18-2026-07-CC-DLII-DX3KUH-20260818081248

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417571
Report Date: 08/06/2026
Date Signed: 08/18/2026 08:13:21 AM

Document Has Been Signed on 08/18/2026 08:13 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:	XU, DI		FACILITY NUMBER:	434417571
ADMINISTRATOR/ DIRECTOR:	DI XU		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 444-2849
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	08/06/2026
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Di Xu		TIME VISIT/ INSPECTION COMPLETED:	12:00 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	On 08/06/2026, at 9:00 AM, Licensing Program Analyst(LPA), Dongzhu Li and Shine Yu (LPA) conducted an announced Pre-licensing inspection. Present for this inspection is the applicant, Di Xu. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation will be from Monday-Friday, 8:30AM-5:30PM. LPAs toured the indoor and outdoor areas during today's visit. The home is neat and clean for safety. The home has central heating and a portable air conditioning unit for ventilation and comfort. The on limit areas are the living room, dining room, half bathroom, kitchen and outdoor play area. The off limit areas include, garage and 4 bedrooms. All off limit areas will be inaccessible by closed and/or locked doors and with visual supervision. The isolation area will be at the living room. The outdoor play area is free from defects or dangerous conditions. LPAs observed a barricaded fireplace in the dinning room. There are ample age-appropriate toys that appear to be safe and in good condition. LPAs observed an empty water basket, round in shape and approximately 4 feet in diameter. LPAs advised the applicant to empty the water basket each time after use. There are no pools or hot tubs at the facility. All hazardous materials and poisons are kept out of reach to children. The Applicant states that any poisons are stored in a locked cabinet under the kitchen sink. LPAs reminded Applicant that smoking, sleep sacks, baby walkers, and similar items are not allowed in Family Child Care Homes. The home has a fully charged 3A40BC fire extinguisher, working carbon monoxide detector, and working telephone and smoke detector that was functioning. Fire clearance was received from the Santa Clara Fire Department and is on file. The Applicants pediatric CPR and First Aid certificate is current and expires 06/08/2028. Applicant completed the Mandated Reporter Training for Child Care Providers on 07/20/2026 and a copy of the certification is on file. Applicant was reminded of Mandated reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the Applicant’s immunization is on file. Continued on 809- C

Gladys Kuizon
Dongzhu Li
	DATE: 08/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: XU, DI	FACILITY NUMBER: 434417571
	VISIT DATE: 08/06/2026

NARRATIVE

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The applicant stated there are no firearms in the home. Applicant has a First Aid kit with a thermometer in the home. Also discussed with Applicant were the requirements for reporting suspected child abuse, unusual incidents/injuries, and heat related illnesses.

Forms of discipline to be used by Applicant is redirection, talking with the child and thinking time. LPAs and applicant discussed time out will be in accordance to the child's age. Applicant 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. LPAs informed the Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

The applicant provided proof of control of property and it is on file. The LPAs observed the Property Owner/Landlord Notification form (LIC9151) and a signed Property Owner/Landlord Consent form (LIC 9149) are on file. The applicant does have liability insurance at this time. LPAs reminded the applicant that if she does not have liability insurance, she is required to provide the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) to all enrolling families.

LPAs reviewed with the Applicant, the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Pre-licensing Entrance Checklist – Family Child Care Homes (LIC 9280) was provided to the Applicant.

Applicant, Di Xu was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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) or (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.

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Dongzhu Li
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

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: XU, DI	FACILITY NUMBER: 434417571
	VISIT DATE: 08/06/2026

NARRATIVE

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On this date, 07/03/2026 the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, 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.

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-carelicensing/subscribe and select the Child Care option to receive email communication.

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/‌inspection-process

Exit interview conducted and report was reviewed with the Applicant in Mandarin, Di Xu. LPAs advised the applicant that a Large Family Child Care Home license will be approved pending Licensing Program Manager’s review.

NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Dongzhu Li
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2026

LIC809 (FAS) - (06/04)

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