<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021150
Report Date: 06/09/2023
Date Signed: 06/09/2023 01:55:12 PM

Document Has Been Signed on 06/09/2023 01:55 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:HE FAMILY CHILD CAREFACILITY NUMBER:
198021150
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Xiaoshan HeTIME COMPLETED:
02:00 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 6/9/2023, Licensing Program Analyst (LPA), Carolyn Tuba conducted an announced pre-licensing inspection for the above address. LPA met with Applicant, Xiaoshau He. Applicant guided LPA on a tour of the entire home. Per Applicant, operating hours are from Monday - Friday 8:00 am - 5:00 pm and will not exceed 24-hour care at any time. Applicant states that she will care for the age group of 6 months - 8 years old. The applicant will provide breakfast, PM snack and lunch to the children in care and is looking into a food program in the near future.

This is a one-story home which consists of living room, kitchen, breakfast nook, garage, front yard, back yard, side yard, swimming pool, garden area near the back yard, 4 bedrooms and 4 bathrooms. Areas used by the children will include the living room, bedroom #1 for napping, bathroom #1, breakfast nook, kitchen, and backyard. Per Licensee, areas off limits to the children include bedrooms #2, #3 #4, side yard, front yard, bathrooms #2, #3, #4, garden area, swimming pool and garage.

During the inspection applicant provided a new application updating phone numbers, and updated facility sketch to indicate off-limit areas. Applicant provided LPA with email address to receive notifications from the Department.

The licensee states that 4 adults currently live in the home. All adults present in the home have obtained a criminal record clearance or exemption prior to working, residing, or volunteering in the licensed childcare home. Applicant was reminded that all adults 18 and over living or working in the home, 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/per day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA observed a baby gate in the hallway near bedroom #1 that separates bedrooms #2, and #3. In the backyard children gates were observed that separate the garden area and the side yard. The backyard has a concrete wall that separates the home from existing neighbors.

The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

page 1 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2023
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 4
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: HE FAMILY CHILD CARE
FACILITY NUMBER: 198021150
VISIT DATE: 06/09/2023
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
26
27
28
29
30
31
32
Knives and other sharp utensils are located in a kitchen cabinet which is locked with a child safety lock. Cleaning products were located in the kitchen locked with safety latches under the sink.

There are outlet covers throughout the home. Smoke detectors located in the hallway and bedroom #1 and carbon monoxide detector located in the kitchen area were observed, tested and found to be operable. LPA observed central heating and air conditioning.

Applicant has completed the required health and safety training, the Pediatric First Aid and CPR Exp: 7/15/2024 Applicant has proof of immunization against pertussis and measles, influenza. Proof of Mandated Reporter Training was also submitted.

Applicant states there are 2 cats, but will be kept in bedroom #3.



LPA observed age appropriate toys and learning materials. The valve on the 2A 10BC fire extinguisher located in the kitchen cabinet indicates fully charged and was purchased on 3/15/2023, LPA observed receipt. LPA advised applicant that it is recommended that Fire extinguisher be serviced or purchased annually. First Aid kit is available with all necessary supplies, including tweezers and scissors. Per Applicant, there are no weapons or firearms in the facility, none were observed by LPA.

Per applicant, the back yard will be used for outdoor play. Adjacent to the backyard is a in-ground pool and LPA took photos and filled out Bodies of Water Checklist. LPA found that the pool met all requirements and per applicant children will not be using the pool. Per applicant, children will be supervised at all times during outdoor play in the backyard.

Applicant states that they will care for infants. Children and infants will nap in bedroom #1 and crib/play yards and cots are available.

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.

LPA reviewed with applicant that napping equipment should not block entrances or exits. Infant mattresses must be to be firm with tightly fitted sheets. Loose object, bumpers, objects hanging, or objects attached to the cribs/play yards are not allowed. Each infant should have their own crib/play yard and bedding. LPA informed applicant of the new Safe Sleep page and provided applicant with LIC 9227 Infant Sleep Plan for infants 0-12 months, PIN 20-24-CCP and a sample of a 15-minute sleep check documentation for infants 0-24 months.

Page 2 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: HE FAMILY CHILD CARE
FACILITY NUMBER: 198021150
VISIT DATE: 06/09/2023
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
26
27
28
29
30
31
32
 The isolation area for a sick child waiting to be picked up will be in the hallway outside of bedroom #1.

The following was discussed with the applicant:

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 adult/infant CPR & Pediatric First Aid certification, TB clearance, immunization, Mandated Reporter training certificate www.mandatedreporterca.gov, and a valid criminal record clearance associated to the facility license.

- A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility.

- 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. Sample form was provided.
- Smoking is prohibited in a family child care 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 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 of 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.
- 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. Licensee states she has homeowners insurance.

LPA reviewed with applicant the Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Entrance Checklist was provided to the applicant for reference.

Page 3 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: HE FAMILY CHILD CARE
FACILITY NUMBER: 198021150
VISIT DATE: 06/09/2023
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
26
27
28
29
30
31
32
OTHER INFORMATION THAT WAS DISCUSSED:

- Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices.


Per applicant, there are no dual licenses at this address.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:

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)/ (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


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.

A small family child care license will be issued after final review of documentation and Licensing Program Manager approval. Once licensed, the applicant is required to comply with the terms and limitations stated on the license.


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.


Notice of Site Visit was issued and will remain posted for 30 days.

Exit interview conducted and report was reviewed with the applicant, Xiaoshan He.

Page 4 of 4

SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4