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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414004864
Report Date: 11/16/2023
Date Signed: 11/16/2023 10:41:44 AM

Document Has Been Signed on 11/16/2023 10:41 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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:XIONG, XIAO QINGFACILITY NUMBER:
414004864
ADMINISTRATOR:XIONG, XIAO QINGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 383-2886
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
11/16/2023
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Xiao Qing XiongTIME COMPLETED:
11:00 AM
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On November 16, 2023, Licensing Program Analyst (LPA) Maria Olguin-Leon met with Licensee, Xiao Qing Xiong for an unannounced annual inspection. The purpose of the inspection was explained. Present today was Licensee, spouse/helper and 6 children (2 infant and 4 preschool age). All adults working at facility have fingerprint clearance. Licensee is operating within capacity and ratio requirements on this day. Hours of operation are Monday– Friday, 8:00 am - 6:00pm.

LPA and Licensee toured the home for health and safety hazards. Day Care Areas: Main living room (activity room), 2nd living room, dining room, bedroom (napping purposes), bathroom #1 and backyard. Off Limits Areas: Kitchen, garage, and entire 2nd floor. Kitchen and staircase are properly barricaded with child proof retractable gates. Fireplace in 2nd living room is properly barricaded and secured with a childproof lock. There are floor mats in living room to cushion falls. Home is well light and has proper ventilation. Cleaning supplies and other potentially harmful items are stored inaccessible to children. All electrical outlets are secured with child proof covers. There are plenty of age-appropriate toys, books, child size furnishings, learning material, changing table and cribs. Backyard has plenty of age-appropriate play toys, small slide combo and playhouse. Outdoor backyard patio is concrete and yard is equipped with grass and artificial grass to cushion falls. Backyard is surrounded with a 5 ft. fence. There are no spas, pools, or other bodies of waters.

Home is equipped with a working carbon monoxide detector, smoke detector and a fully charged fire extinguisher. Home is equipped with a sprinkler system. Isolation area for ill children will be in 2nd living room and away from other children. LPA reviewed first aid kit and kit is fully stocked. Licensee uses a cell phone on the premises. Per licensee, there are no weapons or firearms in the home. Licensee provides sheets for playpens and are washed weekly.

Cont. page 2…
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: XIONG, XIAO QING
FACILITY NUMBER: 414004864
VISIT DATE: 11/16/2023
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LPA reviewed 6 children’s records. Licensee maintains an updated Children’s roster. Licensee CPR/FA expires 03/2024. Licensee Mandated Reporter training expires 01/2025. Licensee provides breakfast, lunch, and two snacks to children in care. LPA reminded Licensee to label children's food/bottles brought from home. LPA observed Childcare License, Emergency Disaster Plan (LIC610A) and Parent's rights posted. Last emergency drill was conducted on 10/26/2023 and properly documented. Licensee carries liability insurance via Accord effective 11/2023.

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.

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: https://www.ada.gov/resources/child-care-centers/.

The Licensee was reminded about the Provider Information Notices (PINs) on the CCLD website. Licensee was informed that as of September 1, 2016, a person may not be employed or volunteer at a childcare facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662. LPA's reviewed AB 1207 with the Licensee.

As of January 1, 2018, all staff must complete Mandated Reporter Training every two years. LPAs reminded licensee about Mandated Reporter training available www.mandatedreporterca.com


Cont. page 3...
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
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
SAN BRUNO CC RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: XIONG, XIAO QING
FACILITY NUMBER: 414004864
VISIT DATE: 11/16/2023
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LPA discussed the safe sleep regulations with 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. LPAs 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 sleeping logs, safe sleep plan and ban of sleep sacks.

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.



Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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

No deficiencies were issued today under Title 22 Division 12 of the California Code of Regulations.

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

Exit interview conducted and report was reviewed with the licensee, Xiong Xiao Qing.
SUPERVISORS NAME: Marie Rodriguez
LICENSING EVALUATOR NAME: Maria Olguin-Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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