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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 376102588
Report Date: 11/07/2025
Date Signed: 11/07/2025 03:51:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/04/2025 and conducted by Evaluator Renita Rodriguez
COMPLAINT CONTROL NUMBER: 51-CC-20251104052758
FACILITY NAME:XIAO, MAN FAMILY CHILD CAREFACILITY NUMBER:
376102588
ADMINISTRATOR:MAN XIAOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(269) 532-4083
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:14CENSUS: 2DATE:
11/07/2025
UNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Man XiaoTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Licensee is not requiring day-care children to be immunized.
INVESTIGATION FINDINGS:
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On 11/7/25 at 3:01 p.m. Licensing Program Analyst (LPA) Renita Rodriguez made an unannounced visit to initiate an investigation and deliver findings, for the complaint received on 11/4/25, regarding the above allegation. LPA met with Licensee Man Xiao. LPA was granted entry after identifying self, showing badge, and disclosing the reason for the visit. Present in the home was 1 daycare child. Licensee child under the age of 10 was present also.

Based on the information obtained during interview and documentation reviewed it is determined that the licensee did not obtain the immunization record for child C1. Licensee states the child attended the day care in October 2025 and received care.

The allegation is valid because the preponderance of the evidence has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 12, Chapter number 3) the deficiency is being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Renita Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 51-CC-20251104052758
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108

FACILITY NAME: XIAO, MAN FAMILY CHILD CARE
FACILITY NUMBER: 376102588
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2025
Section Cited
CCR
102418(a)
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102418 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..
This requirment is not met as evidenced by..
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LIcensee states she will obtain immunization record as required by Licensing prior to the child starting at the day care. Licensee sends email with the documents required to be completed by the parents for childs enrollment. Licensee will continue to send all
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Based on interview and record review, the licensee did not ensure that the immunization record was obtained for child in care which poses a potential Health, Safety or Personal Rights risks to persons in care.

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the required documents to the parents for the enrollment process. Licensee understands children shall not attend until all required documentation is received as required by licensing. Licensee will send LPA C1 immunization record by 11/20/25.
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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.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Renita Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 51-CC-20251104052758
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO N. CC RO, 7575 METROPOLITAN DR STE 110
SAN DIEGO, CA 92108
FACILITY NAME: XIAO, MAN FAMILY CHILD CARE
FACILITY NUMBER: 376102588
VISIT DATE: 11/07/2025
NARRATIVE
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The Notice of Site Visit was provided, and LPA observed posting. Licensee is advised it must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Man Xiao. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Renesha Askew
LICENSING EVALUATOR NAME: Renita Rodriguez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3