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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198021150
Report Date: 11/14/2024
Date Signed: 11/14/2024 01:49:23 PM

Document Has Been Signed on 11/14/2024 01:49 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/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 1DATE:
11/14/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Xiaoshan HeTIME VISIT/
INSPECTION 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 11/14/2024 at 9:05 am, Licensing Program Analyst (LPA), Carolyn Tuba conducted an unannounced inspection visit for the above facility. Covid risk assessment was conducted. Initially LPA knocked on the door and there was no answer. LPA called Licensee, Xiaoshan He (aka: Susan) who stated she had run an errand and arrived at approximately at 9:20 am to the home. LPA entered the home through the front door which has security gate. The facility is a small family childcare. LPA met with Licensee who had 1 child with her and was securely in an infant car seat and was removed from the car immediately. LPA spoke with licensee and asked if parents were made aware of the child leaving the facility. Licensee stated that parents are aware, and she will always text parents before leaving if she needs to run a quick errand. Licensee stated that she currently has a total of 5 children enrolled at this time.

LPA consulted about age groups and ratio and provided Licensee the Individual Infant Sleeping Plan (LIC 9227) and Earthquake Preparedness Checklist (LIC 9148). Also discussed was licensee would like to hire an assistant and what is needed.

During the visit at 10:30 am LPA observed the pool area that was inspected during the prelicensing visit on 6/23/2023. LPA conducted another Bodies of Water checklist and tested the 2 pool gates, which were found to be self-closing and self-latching. The pool is surrounded by an iron gate; however, the side area has a wooden fence and plywood. LPA measured and found that it does not meet the requirements of 5 feet and over and Licensee will be replacing the fence.

Family members residing in the home are 4 adults (criminal record clearance on file). There are no minor children living in the home at this time. 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.
page 1 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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
Document Has Been Signed on 11/14/2024 01:49 PM - It Cannot Be Edited


Created By: Carolyn Tuba On 11/14/2024 at 01:03 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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: HE FAMILY CHILD CARE
FACILITY NUMBER: 198021150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(5)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in while the pool is surrounded by a iron fence with self closing and self latching gates, there is a small secion on the side of the pool area that intially had vines but since the prelicensing those vines were removed. LPA observed that there is a wooden fence and plywood, however it requires it be higher then 5 feet. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2024
Plan of Correction
1
2
3
4
Per Licensee she will replcae existing fencing with a higher fence.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Ana Chico
LICENSING EVALUATOR NAME:Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2024


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: HE FAMILY CHILD CARE
FACILITY NUMBER: 198021150
VISIT DATE: 11/14/2024
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
A facility roster was available. Per Licensee, operating hours are from Monday-Friday 8:00 am – 5:30 pm and cares for children ages 3 months to 6 years of age.

Licensee states that she provides the following meals: Breakfast, Lunch and PM snack and is not part of a food program at this time. Parents provide baby food, and formula, however, licensee does have extra on hand. LPA did issue an Advisory as baby food was not labeled with child’s name. Any food items provided by parents must be labeled with child’s name and stored appropriately. LPA advised that breast milk should have the date and child’s name written on the bottle.

Areas used by children were inspected include: Living room, bedroom #1 for napping, bathroom #1, breakfast nook, kitchen, and backyard. Back yard has enclosed area with a child’s gate with bikes, play structure and children’s toys.

Per Licensee areas off limits include: Bedrooms #2, #3 #4, front area, bathrooms #2, #3, #4, garden area, swimming pool and garage. These are kept off-limits and need to be made inaccessible during operating hours.

During today’s inspection LPA was also completing an inspection visit for a licensee initiated to increase capacity from a small to a large family childcare home. LPA received the approved fire clearance from the Fire inspector. The licensee is wanting to add bedroom #2 as an on-limit area for children in care and a pathway in the backyard for children to ride their bikes and has provided an updated sketch however, LPA advised that before adding bedroom #2, and the back yard pathway the following corrections will need to be made.

The following required corrections for bedroom #2:
The 2 additional doors that lead into another room will require locks or child proof doorknobs to keep children from the off-limit areas.
The shelf in the bedroom will need to have items that pose a danger removed.
Sliding glass door will require an alarm to be added since it leads into the back yard near where the swimming pool is located.
page 2 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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: HE FAMILY CHILD CARE
FACILITY NUMBER: 198021150
VISIT DATE: 11/14/2024
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
Outside in the back yard area:
The side yard located in the back has two air conditioning units and Licensee will be adding mesh covers for added safety for the children in care.

Licensee states there are no firearms stored in the home. The home was inspected for safety, comfort, cleanliness, ventilation, and telephone service. LPA verified the phone number and email address, which was found to be correct. Fire and safety drills must be performed every 6 months and documented for review by the Department. Licensee states she conducted a fire drill in August 2024 and was documented. No one smokes at the family childcare home. Parent Board was available with all required forms.

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 EMSA approved, Immunization's (TDAP, MMR, TB, Influenza (or a waiver for the influenza may be in writing), mandated reporter training and a valid criminal record clearance associated to the facility license.

Detergents, cleaning compounds, medications, and other items, which could pose a danger, were determined to be inaccessible to children in care during this inspection. Kitchen knives are kept in a cabinet in a child proof lock and cleaning supplies are under the kitchen sink with a child proof lock which is made inaccessible for children in care. Medications/vitamins were not accessible to children and according to Licensee there are no children on medication at this time.

LPA observed the required 2:A-10:B-C fire extinguisher, which was last serviced October 29, 2024. State Fire Marshall standards, state that fire extinguisher shall be purchased or serviced annually. The smoke and carbon monoxide detector were tested and operating properly during the visit. Currently the facility has no pets at this time.

Licensee cares for children 24 months and younger, and safe sleep was discussed and LPA advised of PIN 20-24 CCP Safe Sleep. LPA observed the 15-minute safe sleep log for children under 24 months and discussed Individualized Infant Safe Sleep Plan for children under 12 months. The licensee has completed training on preventive health & safety practices. Pediatric First Aid and CPR, which includes the EMSA,
page 3 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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: HE FAMILY CHILD CARE
FACILITY NUMBER: 198021150
VISIT DATE: 11/14/2024
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
expires 11/10/2026. There are first aid supplies available including surgical scissors, tweezers and emergency manual. Licensee’s Mandated Reporting Training Certificate expires 5/30/2026. LPA advised that all persons working with children require the AB 1207 Mandated Reporting training which needs to be completed every 2 years. The following link http://www.mandatedreporterca.com/ was provided.

Children and staff files must be maintained and updated as needed and must be available for review by the Department. If children and staff leave the day care all records must be maintained for 3 years after leaving. LPA observed that children’s files were complete. LPA advised that the following documents of the LIC 700, LIC 627 and LIC 995A are required, as well as the immunizations. LIC 282 is also needed if liability insurance is not available.

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 was reminded that all adults 18 and over living or working in the home, 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 Childcare 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. LPA reviewed clearance list.

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 informed 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.
page 4 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
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: HE FAMILY CHILD CARE
FACILITY NUMBER: 198021150
VISIT DATE: 11/14/2024
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
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: https://www.ada.gov/resources/child-care-centers/. There are no children currently taking medication.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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

The deficiency listed on the following page were observed by the LPA and is being cited in accordance with California Code of Regulations Title 22. Please see attached LIC 809-D. The deficiencies that are being cited needs to be cleared to protect the children’s health & safety.

The application for increase in capacity, will require corrections to be submitted and a final review by the Department before issuing the new license. Once licensed, the Licensee is required to adhere to the terms and limitations stated on the license.

A notice of site visit was given and must remain posted for 30 days. An exit interview was conducted, and report was reviewed with the Licensee, Xiaoshan He.
page 5 of 5
SUPERVISORS NAME: Ana Chico
LICENSING EVALUATOR NAME: Carolyn Tuba
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6