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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417440
Report Date: 10/08/2024
Date Signed: 10/08/2024 11:48:35 AM

Document Has Been Signed on 10/08/2024 11:48 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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:XU, YUNFENGFACILITY NUMBER:
434417440
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
10/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Yunfeng XuTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mandeep Kaur and Linke "Kate" Huang conducted an announced
prelicensing inspection. LPAs met with Applicant, Yunfeng Xu, and explained the reason for the inspection. LPA Kate assisted with translation to Mandarin. Purpose of this inspection; Applicant applied for a small Family Child Care Home (FCCH) license. Applicant is the only adult residing in the home.

The hours of operation will be Monday through Friday 8:30AM to 06:00PM. Applicant does not plan on obtaining liability insurance for the day care. Applicant understands that parents will need to fill out
the Affidavit Regarding Liability Insurance (LIC 282) if he does not plan on obtaining liability insurance for the day care.

Applicant has a valid CPR/1st Aid, which expires on 09/14/2026. Applicant's Preventive Health and
Safety certificate and Mandated Reporter training certificate are on file. Applicant completed the Preventative health and Safety training on 08/25/2024 and Mandated Reporter training on 08/26/2024. LPAs reminded Applicant that the Mandated Reporter training and CPR/1st Aid requires renewal every two years. Applicant's immunization records for TB, measles, pertussis, and influenza are also on file.

The applicant provided proof of control of property. Lease agreement is on file.

Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

**Continue on 809-C
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: XU, YUNFENG
FACILITY NUMBER: 434417440
VISIT DATE: 10/08/2024
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LPAs toured the inside and outside of the home with Applicant. Applicant resides in a single story single family home. LPAs observed the barricaded gate and locked doors to the off limit areas. Off limit areas include: Bedroom#1, Bedroom#3, Kitchen, attached Garage and 1 bathroom. LPAs observed Gas water heater, emergency gas shutoff, emergency panel shut off area is located in garage. LPAs observed off limit areas outdoor: part of the backyard, air-conditioning unit, and both sides of the home. Applicant has submitted the facility sketch (Floor Plan) with the labels and is on file. Updated backyard facility sketch was obtained during today's inspection.

Applicant has play area for the children in the part of the backyard of the home and LPAs observed barricaded gate around the playarea. LPAs advised the applicant that children need to be supervised at all times. The home is clean, orderly, including heating and air conditioning, for safety & comfort.

The Applicant has a valid phone in the home. There is sufficient toys, supplies, and equipment for the day care children indoor and outdoor areas..

LPAs observed a fully charged fire extinguisher (3A40BC), working smoke & carbon monoxide detectors, no bodies of water, and fenced backyard. Applicant states that he does not have any pets or weapons/ammunition in the home.

All disinfectants, cleaning supplies, and other items that could pose a risk to children were inaccessible. There were no baby walkers or bouncers observed in the on-limit areas for the children. Applicant understands that baby walkers or other similar items are not permitted for the children. LPAs reminded Applicant that fire/disaster drill need to be conducted every six (6) months and documented.

Forms of discipline to be used by Applicant: talk to the children and have them play with their favorite toy.
Applicant understands that children's personal rights should not be violated; including no corporal punishment. isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed.

**Continue on 809-C**
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: XU, YUNFENG
FACILITY NUMBER: 434417440
VISIT DATE: 10/08/2024
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**Continue from 809-C**

LPAs 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. LPAs 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.

Applicant states that he will not administer medication once she has children in care. Applicant states that a
child will be isolated on the side of the living room if necessary due to illness or communicable disease. Applicant has a First Aid kit with a touchless thermometer in the home.

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 (American Disability Act) 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, available at: http://www.ada.gov/childqanda.htm.

LPAs 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. Entrance Checklist was provided to the applicant.

All adults have cleared criminal record clearance, child abuse index, and TB. 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, 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.

**Continue on 809-C**
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
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 JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: XU, YUNFENG
FACILITY NUMBER: 434417440
VISIT DATE: 10/08/2024
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On this date, 09/09/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

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

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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website athttps://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with Applicant Yunfeng Xu. LPAs advised Applicant that Small Family Child Care Home license will be issued upon completion of the following:

1. Licensing Program Manager (LPM) review and approval.
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
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