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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312384
Report Date: 02/16/2022
Date Signed: 02/16/2022 06:16:20 PM

Document Has Been Signed on 02/16/2022 06:16 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:ZHANG, XIWEIFACILITY NUMBER:
304312384
ADMINISTRATOR:ZHANG, XIWEIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 245-9383
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 12DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Xiwei ZhangTIME COMPLETED:
06:30 PM
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Alanna Gontarek. At 2:00 p.m., upon entry of the facility, LPA was greeted by the licensee's assistant/sister, and allowed entry to the home by licensee's assistant. Upon entry, LPA observed assistant to be alone with 12 napping children, which included (2) infants and(10) preschool age children. Licensee arrived at facility at 2:20 p.m. stating she went to pick up her child down the street, leaving the facility out of compliance with ratio. Licensee was not operating within the licensed capacity as specified on license. This is a violation of Title 22 Division 12 Chapter 1 Article 6 section 102416.5(e). This poses an immediate health and safety risk to the children in care. Licensee stated there are 13 children enrolled.

LPA advised licensee she must be present in the facility, must ensure children in care are supervised at all times, and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training.

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.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. This is a 2-story, 3 bedroom, 3 bathroom home. Off limits areas include: upstairs area- 3 bedrooms and 2 bathrooms, and the garage. Off limits areas are made inaccessible by means of child safety gates and latches. Daycare areas include: living room, kitchen, backyard, and one downstairs bathroom. Licensee stated the children's primary area is the child care room/living room. Per licensee, provides snacks and lunch.



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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ZHANG, XIWEI
FACILITY NUMBER: 304312384
VISIT DATE: 02/16/2022
NARRATIVE
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During today's inspection, LPA observed no furniture in the home. LPA also observed closets to be empty. Pictures were taken. Licensee stated she submitted a relocation application on 1/3/22, and has been sleeping at facility downstairs on a mat watching over her daycare home, while her children and husband sleep at the new home. LPA reviewed copies of documentation for re-location application submitted to licensing office. Copies of documents submitted are as follows: Application (LIC 279), Emergency Disaster Plan (LIC 610a), Licensee and Licensee's husband Criminal Record Statement (LIC 508), and Statement Acknowledging Requirement to Report Child Abuse (LIC 9108) for licensee and licensee's assistant. There are working carbon monoxide and smoke detectors in the home. Based on observation and interview with licensee, licensee could not provide proof of purchase date, and stated purchased fire extinguisher 3 years ago, which poses a potential health, safety or personal rights risk to persons in care. The fire extinguisher does not meet statutory and State Fire Marshall standards. This violates Title 22 section 102417(g)(1). Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are no firearms and/or other dangerous weapons, or any poisons in the facility and none were observed during today's inspection. The LPA advised licensee all poisons need to be locked via combination or key lock. There is a fireplace in the living room screened by a glass cover, and barricaded with a large child's toy, and inaccessible to children in care. The home has age appropriate toys for the ages served. LPA observed knives to be stored in an above cabinet in the kitchen. LPA observed cleaning compounds stored under sink in the kitchen and made inaccessible via latch. LPA verified there is a working telephone service (cellular service). Licensee stated the children use the backyard for outdoor play. There are age appropriate toys for children, and LPA observed no hazards on the yard. LPA observed slide with cushioning underneath. There are no bodies of water on the premises. LPA observed 2 pet water turtles in the kitchen.

The licensee does have a current roster of children in care. LPA observed facility posted forms: License, Disaster Plan, and Parent Rights. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. The licensee and assistant’s Pediatric CPR/First Aid certification both expire on 7/31/2023.

Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Licensee and Licensee's assistant have proof of immunization against influenza, pertussis, and measles.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. The licensee and licensee's assistant are exempt from this requirement due to the training not being available in Mandarin.
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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ZHANG, XIWEI
FACILITY NUMBER: 304312384
VISIT DATE: 02/16/2022
NARRATIVE
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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: http://www.ada.gov/childqanda.htm

CCLD website was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through [email protected] in order to receive Provider Information Notices (PINs) and quarterly updates. Licensee was advised of their responsibility to review the PINs found on the CCLD website.


A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

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. 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.

A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the licensee.


English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative

Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
· Always place infants on their backs for sleeping (LIC 9227)
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold
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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: ZHANG, XIWEI
FACILITY NUMBER: 304312384
VISIT DATE: 02/16/2022
NARRATIVE
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PIN 21-29-CCP Face Covering Requirements and Guidance for Child Care Providers Regarding Coronavirus Disease 2019 (COVID 19) was provided and licensee was to continue to message the “Three W’s”: Wash your hands. Watch your physical distance. Wear a mask. This face covering guidance is for all individuals 2 years and older, except for the exceptions (child’s development, medical exemptions, etc.) that are outlined by CDPH.

Based on LPAs observations and record review, the following violations were observed and are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1, Section 102416.5(e) and 102417(g)(1) on the attached LIC 809D page.

LPA Alanna Gontarek informed licensee, Xiwei Zhang that this report dated (2/16/2022) documents 1 Type A citation. Type A citation shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care. Also, LPA Alanna Gontarek informed the licensee to provide a copy of this licensing report dated 2/16/22 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Exit interview conducted and report was reviewed with the licensee Xiwei Zhang . Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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 [email protected]. 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/process.

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/16/2022 06:16 PM - It Cannot Be Edited


Created By: Alanna Gontarek On 02/16/2022 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ZHANG, XIWEI
FACILITY NUMBER: 304312384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, at 2:00 p.m., upon entry of the facility, LPA observed assistant to be alone with 12 napping children. Licensee arrived at facility at 2:20 p.m. stating she went to pick up her child down the street, during nap time, leaving the facility out of compliance with ratio.the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2022
Plan of Correction
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LPA Gontarek obtained a declaration completed and signed by licensee to remain at facility during operation hours, or will have a qualified substitute. Per licensee, will send completed and signed Acknowledgment forms for each child attending via email by the due date of 2/17/22. LPA provided capacity worksheet for small and large facility ratios. Per licensee, will sign daughter up for afterschool program for Wednesdays, and will send confirmation via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Patricia Magana
LICENSING EVALUATOR NAME:Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 02/16/2022 06:16 PM - It Cannot Be Edited


Created By: Alanna Gontarek On 02/16/2022 at 05:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: ZHANG, XIWEI
FACILITY NUMBER: 304312384

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with licensee, licensee could not provide proof of purchase date for fire extinguisher, and stated purchased fire extinguisher 3 years ago. The licensee did not comply with the section cited above in that the fire extinguisher was not serviced, or purchased, annually per the regulation. The licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2022
Plan of Correction
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Per licensee, will purchase a fire extinguisher by due date of 2/21/22. Per licensee, will send picture of receipt of purchase via email.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Patricia Magana
LICENSING EVALUATOR NAME:Alanna Gontarek
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022


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