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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313681
Report Date: 12/16/2024
Date Signed: 12/24/2024 02:17:58 PM

Document Has Been Signed on 12/24/2024 02:17 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:LI, JIARONGFACILITY NUMBER:
304313681
ADMINISTRATOR/
DIRECTOR:		LI, JIARONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 618-5488
CITY:IRVINESTATE: CAZIP CODE:
92618
CAPACITY: 14TOTAL ENROLLED CHILDREN: 4CENSUS: 4DATE:
12/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Licensee, Jiarong LiTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On 12/16/2024 at 11:30 AM, Licensing Program Analyst (LPA), Christine Jung, conducted an unannounced case management inspection to follow up on an incident that was self-reported to the Department. Upon arrival, LPA met with licensee, Jiarong Li. LPA disclosed the purpose of the inspection and was led on a tour of the facility. There were four (4) children being supervised by the licensee. Hours of operation are Monday through Friday 8:00 a.m. to 5:00 p.m.

An unusual incident report (UIR) was submitted to the Department on 11/26/2024 reporting an injury to Child 1 (C1). The facility reported that on 11/19/2024, five hours after child was picked up from the facility, licensee received a text from C1’s parent regarding swelling on C1’s arm.

During today's inspection, LPA interviewed licensee and two (2) children. Additional children could not be interviewed due to their age. Licensee provided LPA with documents pertinent to the UIR. At this time, the reported incident needs further investigation.

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

Exit interview conducted and report was reviewed with the licensee, Jiarong Li.

End of report.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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