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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413666
Report Date: 07/28/2023
Date Signed: 07/28/2023 01:52:10 PM

Document Has Been Signed on 07/28/2023 01:52 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:FAN, LANA & ZHANG, XIAO MINGFACILITY NUMBER:
434413666
ADMINISTRATOR:FAN & XIAOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 797-8560
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 0DATE:
07/28/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lana Fan & Xiao Ming ZhangTIME COMPLETED:
02:00 PM
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On July 28, 2023, Regional Manager (RM) Tony Studebaker, Licensing Program Manager (LPM) Gladys Kuizon, and Licensing Program Analyst (LPA) Oscar Huang met with Licensees for the purpose of serving a Temporary Suspension Order (TSO) for the Family Child Care Home.

Summary of charges:

1. On July 25, 2023, an infant in care at the facility was found unresponsive in a crib with a loose object. The infant was transported to the hospital where the infant was pronounced dead.

Regional Manager Tony Studebaker explained the appeal rights to the licensees, including the process to file a Notice of Defense. Summary of Charges packets were left for the parents of the children enrolled in the daycare, and the Temporary Suspension Order was posted on the front door as per Title 22 Regulations. The licensees understand that the TSO must remain posted and the removal or concealment of the notice while the temporary suspension order is in effect is punishable as a misdemeanor with a fine up to $500.00, under section 1596.8895 of the California Health and Safety Code. The Licensees further understand that if a hearing is requested, this Order will remain in effect until the Department issues a final Decision in the matters contained by the Accusation, or 30 days after the Department receives a Proposed Decision, whichever is sooner.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2023
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 JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: FAN, LANA & ZHANG, XIAO MING
FACILITY NUMBER: 434413666
VISIT DATE: 07/28/2023
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The Department is reviewing the incident to determine if enhanced civil penalties are warranted.

No deficiencies were issued, exit interview conducted with the Licensees, and Notice of Site Visit was provided and must remain posted for 30 days.

All documents and conversations were translated into Chinese for the providers via certified bilingual LPA, Oscar Huang.

Temporary Suspension Order is in effect as of 5pm today, July 28, 2023.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023
LIC809 (FAS) - (06/04)
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