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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623856
Report Date: 01/29/2024
Date Signed: 01/29/2024 02:35:28 PM

Document Has Been Signed on 01/29/2024 02:35 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:XIONG, DIAFACILITY NUMBER:
343623856
ADMINISTRATOR:XIONG, DIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 329-2063
CITY:SACRAMENTOSTATE: CAZIP CODE:
95838
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
01/29/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Xiong, DiaTIME COMPLETED:
03:00 PM
NARRATIVE
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At 1:30 p.m. on 1/29/2024, Licensing Program Analyst (LPA) Pa Dao Vang met with Licensee, Dia Xiong, for the purpose of an unannounced, required - 3 year inspection. There were 7 children in care. Facility hours of operation are from 6:30 a.m. - 6:30 p.m., Monday thru Friday. Off-limit areas will include the garage, master bedroom and master bathroom.

All individuals subject to criminal background review have obtained a criminal record clearance. Licensee 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/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

A health and safety inspection was conducted in all areas accessible to children. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning combination smoke and carbon monoxide detector. Licensee stated that there are no weapons nor poisons in the home. Toxic and hazardous items were appropriately stored, inaccessible to children.

LPA reviewed staff files. Licensee's CPR and First Aid expires on 10/30/24. LPA observed Mandated reporter training certificate expiring 1/5/2025. There were no children's files to review. LPA informed Licensee of location change for regional office and provided updated parents’ rights forms and postings with current address.

Continued report on LIC809-C...
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: XIONG, DIA
FACILITY NUMBER: 343623856
VISIT DATE: 01/29/2024
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APPLICANT OWNS THE HOME: The Licensee provided proof of control of property. Applicant understand that her own children under 10 years old counts into the ratio.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage athttps://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. LPA discussed about the infant sleep log required for each child under the ages of 1years old. Licensee must checking and documenting each infant sleeping every 15 minutes.



This provider is not currently providing Incidental Medical Services IMS services to children in care. 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: https://www.ada.gov/childqanda.htm.

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

Exit interview was conducted and report was reviewed with the licensee, Licensee Dia Xiong. A Notice of Site Visit and appeal rights were given and must remain posted for 30 days. 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/inspection-process.

In the areas that were evaluated, no deficiencies were cited during inspection. A copy of this report was printed and provided to the Licensee.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Dao Vang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
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