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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417880
Report Date: 05/21/2025
Date Signed: 05/21/2025 04:28:22 PM

Document Has Been Signed on 05/21/2025 04:28 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:JIANG, XUEHUIFACILITY NUMBER:
434417880
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
05/21/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:04 PM
MET WITH:Xuehui JiangTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
NARRATIVE
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On May 21, 2025 at 1:04 PM, Licensing Program Analyst (LPA), Marilou Monico, conducted an unannounced Annual Random Inspection. LPA met with Licensee, Xuehui "Ashley" Jiang, and explained to her the purpose of today's visit. Also present in the home were Licensee's husband (S2), Licensee's adult daughter (S3), Licensee's helper (S1), and eight (8) daycare children: 2 infants and 6 preschool age. Licensee received the Entrance Checklist - Family Child Care Homes (LIC 126). LPA observed all required posting materials. The daycare is open Monday thru Sunday from 8:30 AM to 6:00 PM. There are no active waivers or exceptions for this facility. Licensee stated that there are three (3) adults residing in the home: herself, her husband, and her daughter.

Fire drill was conducted on May 21, 2025. Licensee was reminded that fire/disaster drills must be conducted and documented every six months. LPA observed a fully charged 2A10BC fire extinguisher, covered fireplace, working smoke and carbon monoxide detectors. Cleaning products and sharp objects were stored inaccessible to children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. Off limit areas inside the home: Room 2, Room 3, one bathroom, furnace closet, and garage . Off limit areas outside: left side yard and two storage sheds. LPA advised licensee to notify Licensing for any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. The Licensee was reminded to notify the department prior to any alterations or additions to the home or grounds. Licensee confirmed that there are no weapons or firearms on the premises. There were no bodies of water observed. The home has a working telephone 408-480-9940.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. 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 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: http://www.ada.gov/childqanda.htm

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2025
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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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.

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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: JIANG, XUEHUI
FACILITY NUMBER: 434417880
VISIT DATE: 05/21/2025
NARRATIVE
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Licensee, Xuehui Jiang, 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.

Eight (8) children's files were reviewed during today's inspection for the following records: Notification of Parents Rights (LIC995A), Consent for Emergency Medical Treatment (LIC 627), Identification and Emergency Information (LIC700), Immunization Records, sleep log for children under 2 years old. The eight children enrolled are missing all required documents. Licensee carries daycare insurance. LPA reviewed three helper's file (S1, S2, & S3). S1 and S2 are missing immunizations in measles and pertussis and Mandated Reporter Training.

Licensee has immunizations in measles, pertussis and flu. Licensee has current Mandated Reporter Training expiring on April 11, 2026. Licensee has current CPR/First Aid certification with an expiration date of May 18, 2027. Licensee was reminded that Mandated Reporter Training must be renewed by all staff every 2 years.

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-and-resources/safe-sleep as an additional resource. LPA also reminded 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.


Continuation on next pages:
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
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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: JIANG, XUEHUI
FACILITY NUMBER: 434417880
VISIT DATE: 05/21/2025
NARRATIVE
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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.

Licensee, Xuehui Jiang, 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&R's) throughout California.

As a result of this inspection, Type A and Type B deficiencies were cited on the following pages.

Assembly Bill (AB) 633 was provided and discussed with Licensee. LPA informed the Licensee to provide a copy of this licensing report dated May 21, 2025 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, Xuehui Jiang.

During the exit interview, the Licensee, Xuehui Jiang, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
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Document Has Been Signed on 05/21/2025 04:28 PM - It Cannot Be Edited


Created By: Marilou Monico On 05/21/2025 at 03:10 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JIANG, XUEHUI
FACILITY NUMBER: 434417880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(b)(3)
Staffing Ratio and Capacity
(b) For a Small Family Child Care Home, the maximum number of children for whom care may be provided at any one time, including children under age 10 who reside at the licensee's home, shall be one of the following: (3) More than six and up to eight children, without an additional adult attendant, only if the criteria in
Section 1597.44 of the Health and Safety Code are met.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above. LPA observed eight (8) children: 2 infants and 6 preschool age which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/22/2025
Plan of Correction
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Licensee states she will remove two children in care to be in compliance with Title 22 Regulations and will submit written plan to Licensing by 05/22/25.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Marilou Monico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


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Document Has Been Signed on 05/21/2025 04:28 PM - It Cannot Be Edited


Created By: Marilou Monico On 05/21/2025 at 03:10 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JIANG, XUEHUI
FACILITY NUMBER: 434417880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee's helpers (S1 & S2) are missing Mandated Reporter Training (AB 1207) certificate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee states she will submit Mandated Reporter Training certificate for S1 & S2 by 06/06/25.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee's helpers (S1 & S2) are missing immunizations in measles and pertussis which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee states she will submit proof of immunizations for S1 and S2 by 06/06/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Marilou Monico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


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Created By: Marilou Monico On 05/21/2025 at 03:10 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JIANG, XUEHUI
FACILITY NUMBER: 434417880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Licensee does not maintain sleep log for the two infants (C1 & C2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee states she will start documenting each 15-minute check for the two infants (C1 & C2) and submit completed sleep log by 06/06/25.
Type B
Section Cited
CCR
102417(g)(7)
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Child #1 thru #8 are missing the Identification and Emergency Information (LIC 700) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee states she will send completed LIC 700 for Child #1 thru #8 by 06/06/25.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Marilou Monico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


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