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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416452
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:17:51 PM

Document Has Been Signed on 12/09/2021 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:XIN, GUOYINGFACILITY NUMBER:
434416452
ADMINISTRATOR:GUOYING XINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 899-4933
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
12/09/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Guoying XinTIME COMPLETED:
02:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang met with Licensee, Guoying Xin for an unannounced case management inspection. LPA explained the nature of today’s inspection to Licensee. LPA also observed an assistant and 6 day care children (4 infants & 2 preschoolers) in the home during today's inspection.

LPA learned that the assistant was not associated to the facility. According to the department finger print information, the assistant has a clearance and is currently associated with the other Family Child Care.

California Code of Regulations, (Title 22, Division 12 & Chapter 1), is being cited on the attached LIC 809D along with a civil penalty assessment. Copy of appeal rights provided to the Licensee.

Exit interview conducted with Licensee, Guoying Xin.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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Document Has Been Signed on 12/09/2021 02:17 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 12/09/2021 at 11:27 AM
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: XIN, GUOYING
FACILITY NUMBER: 434416452

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
102370(d)(2)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 102370(j)
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Licensee submit to the employee's criminal record clearnance transfer request along with valid photo copy of driver license to LPA during today's visit.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for a staff 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:Sandy Knight
LICENSING EVALUATOR NAME:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2021


LIC809 (FAS) - (06/04)
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