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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846045
Report Date: 03/22/2024
Date Signed: 03/22/2024 01:55:09 PM

Document Has Been Signed on 03/22/2024 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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:XIAO FAMILY CHILD CAREFACILITY NUMBER:
334846045
ADMINISTRATOR:XIAO,YUHUAN/XIAO,KEWEIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 766-0676
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
03/22/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Yuhan Xiao, LicenseeTIME COMPLETED:
02:05 PM
NARRATIVE
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On date and time listed, Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct an annual inspection. LPA toured the facility, inside and out, records were reviewed, and the following was observed and/or discussed: Present during the inspection was one adult resident and one uncleared adult assistant.

Normal days and hours of operation are: Monday-Friday 8:00AM-6:00PM

OFF-LIMIT AREAS INCLUDE: All of upstairs, Laundry Room, Garage, Office, Downstairs Bedroom
The facility is operating within the licensed capacity and appropriate ratios
· Appropriate supervision provided during this inspection
· A working telephone is present and current number on file
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector present and were tested by the Licensee during this inspection.
· Fireplace is properly screened to prevent access by children
· All hazardous items are stored inaccessible to children
· Toxins are locked
· Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations
· Stairs are barricaded
· Verification of control of property on file
· Facility Sketch, Emergency Disaster Plan & Notification of Parent’s Rights poster are posted
· Mandated Reporter Training expires on (Licensee EXPIRED 6-24-23) (Assistant 3-7-26)
· Pediatric CPR and First Aid Card expires on (Licensee 6/2025) (Assistant NO CPR/1st Aid)
SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045
VISIT DATE: 03/22/2024
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·Health & Safety Certificate - completed on 6-13-21
· No bodies of water at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 Regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys
· Current roster on file
· Documentation of fire and disaster drills on file – Last drill conducted on 1-16-24
· Children’s records are NOT complete
· Employee’s records NOT are complete
· The Licensee was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO09@dss.ca.gov
· Resident and/or staff records reviewed on 3-22-24 indicate that all adults who require caregiver background checks have NOT received all required clearances or exemptions.
· The Licensee can submit transfer forms to associate new individuals or to disassociate someone from your facility at: Associations_Disassociations862@dss.ca.gov
- LPA discussed the safe sleep regulations with Yuhan Xiao, 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 Yuhan Xiao, 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.

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

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045
VISIT DATE: 03/22/2024
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Yuhan Xiao, Licensee 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.

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.


- The Duty Officer is available to answer questions Monday – Friday; 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200

If a Civil Penalty has been assessed during this inspection. Payment is due when billed and the check(s) or money orders shall be made payable to the “California Department of Social Services”. YOU WILL RECEIVE AN INVOICE IN THE MAIL. DO NOT SEND MONEY UNTIL YOU RECEIVE YOUR INVOICE. DO NOT SEND CASH.

See LIC809-D for cited deficiencies.

The Yuhan Xiao, Licensee confirmed that there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045
VISIT DATE: 03/22/2024
NARRATIVE
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A copy of all Type A deficiencies (LIC 809D) cited during this inspection. A copy of all Type A deficiencies cited during this inspection must also be immediately (within 24 hours of the child's next day in care) given to the parents of all children enrolled in the facility and any children enrolled within the next 12 months. LIC 9224 was provided during inspection.

Exit interview conducted and report was reviewed with Yuhan Xiao, Licensee.

A notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Aaron Ross
LICENSING EVALUATOR NAME: Elyse Jones
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2024 01:55 PM - It Cannot Be Edited


Created By: Elyse Jones On 03/22/2024 at 12:47 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, record review and, interview, the Licensee did not meet the above regulation which poses an immediate Health, Safety & Personal Rights risk to the children in care. During the facility tour LPA observed S2 providing supervision and care to the children enrolled, however, S2 is not associated to the facility. Licensee stated, “not yet” when asked for association documentation.
POC Due Date: 03/25/2024
Plan of Correction
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Licensee understands all individuals shall have a Criminal Record Clearance and be associated to the facility prior to working, residing, or volunteering in a licensed facility. Licensee agrees to obtain a Criminal Record Clearance or submit a Criminal Background Clearance Transfer Request for S2 by 3/25/24. $500 assessed
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2024 01:55 PM - It Cannot Be Edited


Created By: Elyse Jones On 03/22/2024 at 12:47 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Licensee did not meet the above regulation which poses a potential Health and Safety risk to the children in care. During the staff file review LPA was unable to review a current Mandated Reporter certificate for S1. The certificate on file expired 6-24-23.
POC Due Date: 03/31/2024
Plan of Correction
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Licensee understands all staff providing supervision and care must have a current Mandated Reporter certificate on file. Licensee understands Mandated Reporter must be re taken every two years. Licensee agrees to complete training at www. Mandatedreporterca.com and submit the certificate of completion to the Department on or by 3/31/24.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Licensee did not meet the above regulation which poses a potential Health risk to the children in care. During the staff file review LPA was unable to review immunizations for C1 and C3.
POC Due Date: 03/31/2024
Plan of Correction
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Licensee understands all children enrolled must have current vaccinations on file and available for review. Licensee agrees to obtain immunizations for C1 and C3 and send to Department on or by 3/31/24.
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:Aaron Ross
LICENSING EVALUATOR NAME:Elyse Jones
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


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