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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416341
Report Date: 01/25/2022
Date Signed: 01/25/2022 03:10:02 PM

Document Has Been Signed on 01/25/2022 03:10 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:HUO, XIAFACILITY NUMBER:
434416341
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 2CENSUS: 2DATE:
01/25/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Xia HuoTIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang met with Licensee Xia Huo for an unannounced case management inspection due to licensee's capacity increase request & Post-Licensing visit. LPA explained the nature of today’s inspection to Licensee. LPA also observed 2 daycare infants in the home during today's inspection. Days and hours of operation are Monday to Friday, 8:30 a.m. to 6:30 p.m. The adults that reside in the home are Licensee & her tenant.

Licensee Xia Huo 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. A review of staff records on today indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home appears clean and orderly, with heating and ventilation for safety and comfort of the children. Licensee was advised to keep temperature within 68-85 degrees. LPA observed no baby walker, bouncers, excer-saucers, jumpers etc. on the premises. LPA observed no stairs inside the home. The main area of the home is used for the day care are Living room, Family room, and bathroom #1. LPA observed a screened fireplace. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items are stored in top cabinets in the kitchen inaccessible to children. LPA observed a fully charged 2A10BC fire extinguisher, at least one working smoke and a functioning carbon monoxide detector. Licensee states there are no weapons/firearms and pets in the home. Off limit areas indoor: all 4 bedrooms, kitchen, and garage. LPA observed a fenced backyard and no bodies of water. Off limit areas outside the home: two gated side yards. Licensee stated there are no weapons/firearms and pets in the home.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HUO, XIA
FACILITY NUMBER: 434416341
VISIT DATE: 01/25/2022
NARRATIVE
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Licensee rents the house, did not carry liability insurance. LPA observed Licensee has current CPR and First Aid certifications expiring 9/2023, and has completed her Preventative Health and Safety Child Care Training which includes an hour of nutrition & the lead poisoning prevention on March 14, 2021. LPA observed a current roster of the children. LPA reviewed all children files mandated by the regulation.

LPA discussed the safe sleep regulations with licenseeand 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. LPA observed Infant Sleeping Plan and 15 minutes check logs, however, LPA did not observe Individual Infant Sleeping PLan (LIC 9227).

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: https://www.ada.gov/childqanda.htm



A fire clearance granted from the Sunnyvale Fire Department was received on 1/14/2022 and was on file: Fire Clearance granted on 1/14/2022: Fire clearance granted to allow capacity change from 8 to up to 14 children. Day care use not permitted in kitchen, garage or bedrooms.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with licensee Xia Huo, and advised her that a Large Family Child Care Home license is now pending upon correcting two deficiencies & management approval:

1: Tenant's TB clearance record within 12 months.


2: Individual Infant Sleeping plan for two infants in care.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
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Document Has Been Signed on 01/25/2022 03:10 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 01/25/2022 at 02:37 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: HUO, XIA
FACILITY NUMBER: 434416341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/09/2022
Section Cited
CCR
102369(b)(9)

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Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
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Licensee agreed to submit her tenant TB clearnace proof to the office by the POC due date.
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Based on record review, the licensee did not comply with the section cited above for her tenant which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/01/2022
Section Cited
CCR102425(c)

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An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.
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Licensee agreed to sumit signed and dated by the infant’s authorized representative, and submit the log to the office by the POC due date.
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Diana Stephenson
LICENSING EVALUATOR NAME:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022


LIC809 (FAS) - (06/04)
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