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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409304
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:37:22 PM

Document Has Been Signed on 07/08/2022 01:37 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:DONG, XINFACILITY NUMBER:
073409304
ADMINISTRATOR:DONG, XINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 779-4560
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/08/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Xin DongTIME COMPLETED:
01:40 PM
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On 7/8/2022 at 11:00 AM, Licensing Program Analysts (LPAs) Christina Watts and Morgan Pringle conducted an announced Pre-licensing Inspection and met with Applicant, who has applied for a Large Family Child Care Home with a capacity of fourteen (14). Living in the home are applicant, applicant spouse and applicant two minor children ages 3 and 5 years old. Days and hours of operation will be Monday – Friday from 8am - 6pm.

Applicant completed 8 hour Preventative Health & Safety training, Nutrition and Lead Poisoning training, 8 hour Pediatric CPR & First Aid Certificate that expires 06/2023, has documentation for Measles, Pertussis, Influenza opt out statement for the current flu season. Applicant and adults living in the home have Criminal Record and Child Abuse Index Clearance and documentation for Tuberculosis (TB) clearance. Applicant owns the home. LPA reminded that when care for more than twelve and up to fourteen is provided, Applicant must notify parents. Applicant will use the Affidavit Regarding Liability Insurance form to inform parents they do not carry a day care insurance. Applicant has a working telephone in the home. Fire Safety Clearance was given to this facility on 06/29/2022 by El Cerrito Fire Department.

Two story Home comprises of 3 bedrooms, 3 1/2 bathrooms, Family/Guest Room, Office, Kitchen, Dining room, Living room(class room)
Areas on limits: Living Room (classroom), Half bathroom, Backyard
Off-Limit Areas: 3 bedrooms including master bedroom, 3 bathrooms, Office, Family/Guest Room, Landry Room, attached garage, outdoor storage.
Isolation Area: Nook Area
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Christina Watts
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: DONG, XIN
FACILITY NUMBER: 073409304
VISIT DATE: 07/08/2022
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LPA toured the indoor space of the home. The home is sanitary and orderly, with heating and ventilation for safety and comfort. There are stairs in the home. Stairs are made inaccessible to children. Fireplace is located in the Living Room(classroom) and family room and covered by baby gate. LPA advised applicant to cover fireplace in living room with an item that children cannot move. LPA observed fully charged 2A10BC fire extinguisher, working smoke, carbon monoxide detector. Medicines, cleaning products, sharp objects are stored inaccessible to children. Door access to off limit areas are made inaccessible to children. LPA reminded that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care homes. Applicant states there are no firearms and ammunition stored in the home.


Outdoor Space: LPA toured the outdoor areas. On the left side of facility, there is a wooden gate that facility will use as entrance and exit for parents. The entrance leads to the backyard of facility. Children will be using the backyard for outdoor activity. The yard has fences on all sides. LPA observe fence in the backyard was leaning (See LIC9102TA). No bodies of water were observed. On left hand side near parents entrance, there is a storage room. LPA advised applicant to make door inaccessible to children while they are in care.

Applicant understands that children's personal rights should not be violated and no corporal punishment. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire drills must be conducted once every six months and documented. A Family Child Care Home packet was provided to and reviewed with the Applicant.

LPA discussed and reminded Applicant day care needs to be operated within the limitations and capacity of a Large Family Child Care Home with regards to ratios and that Licensee has to be present in the day care for 80% of the operation hours.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Christina Watts
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: DONG, XIN
FACILITY NUMBER: 073409304
VISIT DATE: 07/08/2022
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This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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)/ (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.

LPA discussed the safe sleep regulations with Applicant, and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant 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.

Applicant 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Website links for provider resources:


Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov.

Exit interview was conducted with Applicant, Xin Dong and she signed the report acknowledging receipts of documents.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Christina Watts
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: DONG, XIN
FACILITY NUMBER: 073409304
VISIT DATE: 07/08/2022
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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 platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication or email:childcareadvocatesprogram@dss.ca.gov

LPA reviewed with Applicant the LIC311D, Forms/Records To Keep In Your Family Child Care Home, Children's Forms/Records, Facility Forms/Records, and Information to be Posted.

Entrance checklist was provided to the Applicant.

At 1:00 PM, exit interview conducted with Applicant, Xin Dong.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Christina Watts
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
LIC809 (FAS) - (06/04)
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