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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334846045
Report Date: 01/15/2026
Date Signed: 01/15/2026 12:29:04 PM

Document Has Been Signed on 01/15/2026 12:29 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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME:XIAO FAMILY CHILD CAREFACILITY NUMBER:
334846045
ADMINISTRATOR/
DIRECTOR:		YUHUAN XIAOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(858) 766-0676
CITY:EASTVALESTATE: CAZIP CODE:
92880
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 15DATE:
01/15/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:54 AM
MET WITH:Yuhuan Xiao, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:38 PM
NARRATIVE
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On date and time listed above, Licensing Program Analyst (LPA) Elyse Jones arrived at the facility to conduct an annual inspection and was granted entry by Yuhuan Xiao, Licensee. LPA toured the facility, reviewed records, and observed and/or discussed the following:

Days and hours of operation are Monday- Friday, 8:00AM-6:00PM

OFF-LIMIT AREAS INCLUDE: All of upstairs, Garage, Downstairs Bedroom, Laundry Room, left side yard when facing the house

The inspection consisted of reviews of the CARE tool domains. The inspection found the facility to be in compliance except as noted on the LIC809D. Deficiencies were cited/not cited this visit.

Licensee is present and was not operating within the licensed capacity with appropriate supervision and ratio during the entire inspection.

A working telephone and appropriate fire extinguisher are present.


Smoke and carbon monoxide detectors are present and were tested by the Licensee during this inspection.
All hazardous items are inaccessible to children
Fireplace is properly screened
Stairs are properly barricaded
NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Elyse Jones
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045
VISIT DATE: 01/15/2026
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Facility is clean, orderly and has adequate heating and ventilation
Facility has safe, age-appropriate toys for indoor and outdoor activities outdoor play area is fenced.
Verification of control of property on file
The following postings are visible: License, Emergency Disaster Plan (LIC610) and Earthquake Preparedness Checklist (LIC9148); Parent’s Rights Poster (PUB393); Personal Rights; Child Car Seat Law and facility sketch.
Pediatric CPR and First Aid Card S1: expired 6-2025 S2: expires 5-6-2026 not EMSA approved
Health & Safety Certificate on file
Mandated reporter: Child Care S1: expires 3-31-2026 S2: expires 11-12-2027
Fire clearance on file
Documentation of fire & earthquake drills completed on 10-6-2025
Children/Infant records are not complete
Employee records are not complete
Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 regulations.

There are no bodies of water during this visit Licensee understands all bodies of water must be properly covered or fenced per Title 22 regulations. The Department must be notified before and after installation of the above types of water bodies.

Additionally, the following was reviewed with Licensee.


- AB 1207 – Mandated Child Abuse Reporting: Child Day Care Personnel Training, beginning January 1, 2018 – Requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years.
-AB2960 – This bill requires the State Superintendent of Public Instruction (SSPI), within the California Department of Education (CDE), to develop and post on CDE's website a comprehensive childcare and development services online portal for families and providers by June 30, 2022.
NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Elyse Jones
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045
VISIT DATE: 01/15/2026
NARRATIVE
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Effective January 1, 2017 – Children under 2 years of age shall ride in a rear-facing car seat unless the child weighs 40 or more pounds OR is 40 or more inches tall. For additional information regarding car seat laws see www.chp.ca.gov

-Unusual Incident Reporting email: UnusualIncidentReportsDO09@dss.ca.gov


-Duty Officer availability: Mon. – Fri. at 1-844-LET-US-NO (1-844-538-8766)
-Access to forms & Regulations online at www.ccld.ca.gov
-Licensee is responsible to know the regulations for anyone providing care
-Failure to meet the posting requirements shall result in an immediate civil penalty
-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

Yuhuan Xiao, 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.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.



Yuhuan Xiao, 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 Child Care 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.
NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Elyse Jones
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
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
RIVERSIDE CC RO, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501
FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045
VISIT DATE: 01/15/2026
NARRATIVE
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Safe Sleep- Licensee is not caring for children under two years old at the time of this inspection

Yuhuan Xiao, Licensee of the importance of checking for and removing any 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.

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.

See LIC809D for cited deficiencies.

LPA Jones informed Yuhuan Xiao, Licensee that this report dated 1-15-2026 document(s) one Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Jones informed Yuhuan Xiao, Licensee to provide a copy of this licensing report dated 1-15-2026 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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

A notice of site visit was given and must remain posted for 30 days.

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

NAME OF LICENSING PROGRAM MANAGER: Aaron Ross
NAME OF LICENSING PROGRAM ANALYST: Elyse Jones
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/15/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 12:29 PM - It Cannot Be Edited


Created By: Elyse Jones On 01/15/2026 at 11:22 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(a)
Staffing Ratio and Capacity
(a) The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation and interview, the Licensee did not meet the above regulation which poses an immediate Health, Safety & Personal Rights risk to the children in care. Upon arrival there were 12 children present. At approximately 9:40AM three children were dropped off putting the Licensee over capacity with 15. The Licensee stated a child who does not regularly attend, showed up. The Licensee was over capacity for approximately 10 minutes.
POC Due Date: 01/16/2026
Plan of Correction
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During the inspection one child was picked up. Licensee agrees to submit a written statement of understanding. The statement should include a plan to ensure she is always in compliance with the capacity. Statement is due on or by POC due date of 1-16-2026.
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.
Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:
Elyse Jones
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 12:29 PM - It Cannot Be Edited


Created By: Elyse Jones On 01/15/2026 at 11:22 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the 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 review the LPA was unable to review a current EMSA approved CPR/1st Aid certificate.
POC Due Date: 01/30/2026
Plan of Correction
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Licensee understands at least one staff present and working with the children must have a current EMSA approved CPR/1st Aid certificate on file. Licensee agrees to have S1 and S2 complete training and submit the certificate of completion to the Department on or by POC due date of 1-30-2026.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the 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 the LPA was unable to review a TB clearance for S2.
POC Due Date: 01/22/2026
Plan of Correction
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Licensee understands all adults residing, working or volunteering in the home must have a TB clearance on file and available for review during the inspection. Licensee agrees to obtain proof od TB clearance and submit to the Department on or by POC due date of 1-22-2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:
Elyse Jones
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 12:29 PM - It Cannot Be Edited


Created By: Elyse Jones On 01/15/2026 at 11:22 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 the record review, the Licensee did not meet the above regulation which poses a potential health risk to the children in care. During the children’s file review the LPA was unable to review immunizations for C1.
POC Due Date: 01/22/2026
Plan of Correction
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Licensee understands all children must have immunizations prior to enrollment. Immunization records must be on file and available for review during the inspection. Licensee agrees to obtain immunization records for C1 and submit to the Department on or by the POC due date of 1-22-2026.
Type B
Section Cited
CCR
102418(g)(1)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential health risk to the children in care. During the children’s file review the LPA was unable to review immunizations on a PM 286 form.
POC Due Date: 01/22/2026
Plan of Correction
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Licensee understands the children’s immunizations must be transferred to the PM 286 form for all children enrolled. Licensee agrees to submit a completed PM 286 for C1, C2, C3, C4, C5 and C5 to the Department on or by POC due date of 1-22-2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:
Elyse Jones
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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Created By: Elyse Jones On 01/15/2026 at 11:22 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential safety risk to the children in care. During the facility tour the LPA reviewed a roster that was not current.
POC Due Date: 01/15/2026
Plan of Correction
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Licensee understands all children enrolled must be listed on the facility roster. Licensee corrected during inspection.
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential health risk to the children in care. During the children’s file review the LPA was unable to review LIC 282 Affidavit Regarding Liability Insurance for Family Child Care Home. Licensee stated she has liability insurance but was unable to locate the documentation.
POC Due Date: 01/15/2026
Plan of Correction
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Licensee agrees to obtain signed LIC 282 for all children enrolled. Licensee agrees to submit LIC 282 for C1, C2, C3, C4, C5 and C6 or a copy of the current liability policy on or by the POC due date of 1-22-2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:
Elyse Jones
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/15/2026 12:29 PM - It Cannot Be Edited


Created By: Elyse Jones On 01/15/2026 at 11:31 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
, 3737 MAIN ST., SUITE 700
RIVERSIDE, CA 92501

FACILITY NAME: XIAO FAMILY CHILD CARE
FACILITY NUMBER: 334846045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/15/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
102421(d)(1)
(d) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child's record, proof of parent notification that the facility is caring for an additional child as required in Section 102416.5(h).
(1) The licensee shall maintain a completed and signed LIC 9150 (Rev. 8/14) Parental Notification Additional Children in Care, which is incorporated by reference, for this purpose.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the record review, the Licensee did not meet the above regulation which poses a potential health risk to the children in care. During the children’s file review the LPA was unable to review LIC 9150 Parent Notification Additional Children in Care
POC Due Date: 01/22/2026
Plan of Correction
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Licensee agrees to obtain signed LIC 9150 for all children enrolled. Licensee agrees to submit LIC 9150 for C1, C2, C3, C4, C5 and C6 on or by the POC due date of 1-22-2026.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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.
Aaron Ross
NAME OF LICENSING PROGRAM MANAGER:
Elyse Jones
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/15/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2026


LIC809 (FAS) - (06/04)
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