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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198018983
Report Date: 04/20/2021
Date Signed: 04/20/2021 11:33:22 AM

Document Has Been Signed on 04/20/2021 11:33 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:BAO FAMILY CHILD CAREFACILITY NUMBER:
198018983
ADMINISTRATOR:XUEFEI BAOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 456-1322
CITY:ARCADIASTATE: CAZIP CODE:
91007
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 8DATE:
04/20/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Xuefei Bao - LicenseeTIME COMPLETED:
11:45 AM
NARRATIVE
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An unannounced in person Case Management – Deficiencies inspection was conducted by Licensing Program Analyst (LPA) Nolan Tcheng for the purpose of citing deficiencies found during inspection. Upon arrival at 9:30am, LPA was greeted by Assistant Hong Xie and let into the facility. LPA met with Licensee Xuefei Bao, to whom the purpose of the inspection was announced.

At 9:35am, Licensee provided a tour of the facility and census was taken. There were eight children present during the time of inspection. Staff child ratio was met.

During our investigation, photographs and disclosures from Staff #1 and Adult #1 confirm that the injuries sustained to the front of Child #9’s (C9) face occurred on 03/29/2021. Based on lack of an Unusual Incident Report on file, the injuries to C9’s head were not reported and not brought to the Department’s attention. During course of investigation, the facility was visited by Arcadia Police Department during operation hours. According to Arcadia Police Department, a visit was conducted on 04/06/2021 at approximately 2pm. The visit from Arcadia Police Department was not reported to Department. Therefore, Staff #1 failed to report to the Department the above incidents and is in violation of Title 22 regulations. Please see attached 809-D for documentation of deficiency.

Children’s file review was conducted during today’s inspection, at 10:30am to verify that LIC 9224 Acknowledgement of Receipt of Licensing Reports was signed for the Type A citation issued for the facility being Out-of Ratio on 04/02/2021. LPA observed 10 of 10 files containing the signed LIC 9224.

During today’s inspection, a citation issued on 04/02/2021 was cleared. Licensee provided a statement. Deficiency cleared and Letter of Deficiency Cleared has been provided to Licensee Xuefei Bao on this date.

REPORT CONTINUES PAGE 1 of 2

SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE: DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/20/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: BAO FAMILY CHILD CARE
FACILITY NUMBER: 198018983
VISIT DATE: 04/20/2021
NARRATIVE
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The deficiencies listed on the following page were observed by the LPA and are being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809D for deficiencies that are being cited and need to be cleared to protect the children’s health & safety.

Notice of Site Visit was given to Licensee. The Notice of Site Visit shall be posted for thirty (30) consecutive days. Failure to maintain posting will result in a $100 Civil Penalty.



An exit interview was conducted with Licensee Xuefei Bao, at 11:20am. A copy of this report was signed and appeal rights were provided to licensee.

END OF REPORT PAGE 2 of 2
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/20/2021 11:33 AM - It Cannot Be Edited


Created By: Nolan Tcheng On 04/20/2021 at 09:58 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: BAO FAMILY CHILD CARE
FACILITY NUMBER: 198018983

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/27/2021
Section Cited
CCR
102416.2(b)(3)(C)

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102416.2(b)(3)(C) Reporting Requirements
The licensee shall report to the Department any…unusual incidents or child absence that threatens the physical or emotional health or safety of any child.

This requirement was not met as evidenced by:
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Per Licensee, licensee will submit an LIC624B unusual incident report for the incident that happened to child's head by POC date. Licensee will also watch video at ccld.childcarevideos.org on Reporting Requirements and submit a summary by POC date 04/27/2021
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Based on interview, Licensee did not notify the Department when Child #9 sustained injuries to their head. This poses a potential risk to the health, safety, and personal rights of children in care.
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Type B
04/27/2021
Section Cited
CCR102416.2(b)(3)(C)

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102416.2(b)(3)(C) Reporting Requirements
The licensee shall report to the Department any…unusual incidents or child absence that threatens the physical or emotional health or safety of any child.

This requirement was not met as evidenced by:
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Per Licensee, licensee will submit an LIC624B unusual incident report for when Arcadia Police Department visited during operation hours. Licensee will also watch video at ccld.childcarevideos.org on Reporting Requirements and submit a summary by POC date 04/27/2021
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Based on interview, Licensee did not notify the Department when Adult #2 of Arcadia Police Department visited the facility during operation hours. This poses a potential risk to the health, safety, and personal rights of 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:Christina Gabelman
LICENSING EVALUATOR NAME:Nolan Tcheng
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2021


LIC809 (FAS) - (06/04)
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