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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004864
Report Date: 01/19/2022
Date Signed: 01/19/2022 11:21:38 AM

Document Has Been Signed on 01/19/2022 11:21 AM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:XIONG, XIAO QINGFACILITY NUMBER:
414004864
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 4CENSUS: 0DATE:
01/19/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Applicant, Xiao Qung XiongTIME COMPLETED:
11:30 AM
NARRATIVE
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On January 19th, 2022, Licensing Program Analyst (LPA) Kassandra Medrano met with applicant, Xiaoqing Xiong, and her husband, Timothy, for a Change of Location and Capacity Increase inspection at the facility. Applicant now lives in a two story single family home with husband. Hours of operation will be Monday to Friday, 8:00 AM to 6:00 PM. Child care will be provided in areas: Front Room, Living Room, Backyard, Crib room, and Bathroom #1 Off limit areas: Front Yard, Kitchen, Entire Second floor, Garage. All off limits areas must be made inaccessible to children. Applicant was notified that prior to use of any off limits area, the department must be notified. With applicant, LPA inspected the entire home for health and safety hazards. The house is in good repair and free of any hazards with proper temperature and ventilation. All toxins or dangerous materials are stored in off limit areas keeping them inaccessible for children. Fireplace and stairs are barricaded. The house has a working telephone, fully charged 2A10BC fire extinguisher, smoke detector and carbon monoxide detector. There are first aid supplies available and stored in kitchen. All of the medications are inaccessible to the children. Applicants CPR is current and expires 2/2023. There is a variety of age appropriate toys available. As per the applicant, there are no firearms or weapons in the home. Applicant states there are no pets on the premises. There is no pool, spas or other bodies of water. All electrical outlets are properly covered. Meals and snacks will be provided by the applicant. Discipline policy will be redirection, talking to the child and in some cases time out. Applicant was informed that time outs cannot be any longer than one minute per age of the child and can not exceed five minutes. Isolation of an ill child will be in the Crib room. Applicant 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.
SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: XIONG, XIAO QING
FACILITY NUMBER: 414004864
VISIT DATE: 01/19/2022
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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. LPA discussed the safe sleep regulations with applicant 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 applicant\ 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 reviewed with applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. 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.

LPA to recommend applicant for approval as well as capacity increase as of today, January 19,2022

Exit interview conducted and report was reviewed with the applicant, Xiao Qing.

SUPERVISORS NAME: Ali Zebila
LICENSING EVALUATOR NAME: Kassandra Medrano
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
LIC809 (FAS) - (06/04)
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