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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413666
Report Date: 03/21/2024
Date Signed: 03/21/2024 03:41:56 PM

Document Has Been Signed on 03/21/2024 03:41 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:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 0TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
03/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Lana Fan & Xiao Ming ZhangTIME COMPLETED:
09:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Oscar Huang met with licensee, Xiao Ming Zhang for an unannounced case management visit for the purpose of serving non-compliance deficiencies to the Family Child Care Home.

The facility did not conduct infant safe sleep practices by having an infant napped with a loose object in a crib, nor did maintain documentation/records for physically checks on the infant every 15 minutes.

Deficiencies are being cited on the attached LIC 809-D.

The report was discussed and verbally translated into Chinese during the exit interview with Licensee, Xiao Ming Zhang.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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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Document Has Been Signed on 03/21/2024 03:41 PM - It Cannot Be Edited


Created By: Yangcheng Huang On 03/20/2024 at 03:18 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: FAN, LANA & ZHANG, XIAO MING
FACILITY NUMBER: 434413666

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/21/2024
Section Cited
CCR
10245(b)

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INFANT SAFE SLEEP: (b) Cribs or play yards shall be free from all loose articles and objects.
This requirement is not met as evidenced by:
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The Department issued a Temporary Suspension Order on 07/28/23. No Notice of Defense received.
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Licensees did not comply with the section cited above by using a baby disposal underpad flush with the mattress under a napping infant which posed an immediately health, safety risk to children in care.
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Type A
03/21/2024
Section Cited
CCR102425(j)(1)(D)

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INFANT SAFE SLEEP: (j)The provider shall supervise infants while they are sleeping and adhere to the following requirements: (1)The provider shall physically check on the infant every 15 minutes. (D) Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: a. Date.
b. Infant’s name.
c. Time of each 15-minute check.
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The Department issued a Temporary Suspension Order on 07/28/23. No Notice of Defense received.
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Licensees did not comply with the section cited above by not maintain documentation/records for physically checks on the infant every 15 minutes. which posed an immediately health, safety risk to children 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:Gladys Kuizon
LICENSING EVALUATOR NAME:Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
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