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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021051
Report Date: 09/14/2022
Date Signed: 09/14/2022 01:58:21 PM

Document Has Been Signed on 09/14/2022 01:58 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:XIE FAMILY CHILD CAREFACILITY NUMBER:
198021051
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
09/14/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:41 PM
MET WITH:Hong XieTIME COMPLETED:
02:10 PM
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An announced Pre-Licensing inspection was conducted by Licensing Program Analyst (LPA) Jennifer Hua. A risk assessment was conducted upon entry and appropriate COVID PPE was used. Pre-licensing Entrance Checklist (LIC 9280) was provided. The purpose of today's visit is to inspect and evaluate facility for initial licensure, Applicant is applying for a Small Family Child Care Home. Present during this inspection was Applicant Hong Xie

Per applicant, members residing in the home are 4 adults and 1 minor. Per applicant, operation hours will be Monday to Friday, 7am - 6:00 PM. Applicant states that she will care for children age birth to 14 years old.

During this inspection the following was observed:

All areas identified on the facility sketch were inspected, including but not limited to, all off limit areas. This is a single story home that consists of 4 bedrooms, 2 bathrooms, kitchen, living room, dining room, and garage. Landlord consent on file.

Per applicant, the children will use hall bathroom, living room, dining room and fenced section of the patio for outdoor play. Areas that will be used by children were inspected for safety, comfort, cleanliness, ventilation and heating. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible in areas designated for children.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2022
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 6
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: XIE FAMILY CHILD CARE
FACILITY NUMBER: 198021051
VISIT DATE: 09/14/2022
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The applicant states that there are no poisons on the premises.

Areas off limits to children and parents are: All bedrooms (safety gate and safety door knobs in place), kitchen (safety gate in place), side yards and back portion of backyard. All areas inaccessible for children were observed to have a child-proof security gate making them inaccessible for children in care. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

LPA observed a fire extinguisher mounted by kitchen, The valve on the 2A10BC fire extinguisher indicates fully charged. Smoke and carbon monoxide detectors were tested during the inspection and observed to be operable.

There are toys available for children. LPA observed sleeping arrangements in the form of mats. LPA advised applicant of safe sleep regulations.

The applicant states that they will provide food for children in care.

The applicant has completed the required Health and Safety Training, Nutrition and Lead Training, Mandated Reporter Training, and Pediatric First Aid and CPR. There are first aid supplies available.

Per applicant, there are no firearms or weapons, or bodies of water, no dogs in the facility and LPA did not observe any on this day.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: XIE FAMILY CHILD CARE
FACILITY NUMBER: 198021051
VISIT DATE: 09/14/2022
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The children will use the fence portion of the patio for outdoor play.

Applicant states she will care for children from birth to 14 years old. LPA discussed the safe sleep regulations with Applicant 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 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.

INFANT CARE: The infant will sleep in the day care where they are constantly supervised. Appropriate sleeping arrangements and cribs will be available/observed. (one crib for each infant in care is required). Cribs or play yard will not hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Cribs and play yards shall be free of loose articles and objects. No objects shall be hanging above or attached to the side of the crib. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and document the time of each 15-minute LIC 9227 Plan shall be completed for each infant up to 12 months of age. LPA provided the licensee with a copy of A Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. LPA also consulted and explained Child Abuse Reporting, Never Shake a Baby, and Safe Sleeping practices.

· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Civil Penalties will be assessed if not in compliance.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6
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: XIE FAMILY CHILD CARE
FACILITY NUMBER: 198021051
VISIT DATE: 09/14/2022
NARRATIVE
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· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
· Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
· Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a family childcare home.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
· Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: XIE FAMILY CHILD CARE
FACILITY NUMBER: 198021051
VISIT DATE: 09/14/2022
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· Isolation for Ill children: When a child is ill he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home).
· Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information.

· Immunization Requirement: H&S 1597.622: 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. The applicant has proof of immunizations.

· Mandated Reporter Training: H&S 1596.8662: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com

LPA reviewed and issued the LIC 311D - Forms/Records to Keep in Your Family Child Care Home. All required forms listed were explained. Applicant states she has all the required forms.



LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov.

OTHER INFORMATION AND FORMS PROVIDED:
· Handouts provided for Safe Sleeping practices
· Car Seat Law - Applicant stated will print from website
· Lead Exposure Flyer

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: XIE FAMILY CHILD CARE
FACILITY NUMBER: 198021051
VISIT DATE: 09/14/2022
NARRATIVE
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LPA consulted with applicant regarding COVID-19 health and safety guidelines on this date.

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 (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


The applicant’s signature on this report acknowledges that they have signed the Application for a Family Child Care Home License (LIC 279) under the penalty of perjury that the statements on the application and any attachments are correct.

Facility is ready to be licensed.

Once licensed, the applicant is required to adhere to the terms and limitations stated on the license.

Exit interview conducted and report was reviewed with Applicant Hong Xie.

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SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Jennifer Hua
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2022
LIC809 (FAS) - (06/04)
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