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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434413666
Report Date: 02/23/2022
Date Signed: 02/23/2022 11:11:10 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/17/2022 and conducted by Evaluator Yangcheng Huang
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20220217145356
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:14CENSUS: 11DATE:
02/23/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lana Fan & Xiao Ming ZhangTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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License did not properly report an incident involving a daycare child
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Oscar Huang made a 10-day initial complaint investigation to the facility. LPA met with Licensees Lana Fan & Xiao Ming Zhang, and discussed the above allegation with them. LPA also observed a helper and evelen daycare chidlren (an infant & 10 preschoolers). LPA interviewed licensees, the helper, and obtained copies of pertinent documents.

Based on interview of Licensees, the helper, as well as LPA's own observations for the complaint allegation listed above. LPA concludes that the preponderance of evidence standard has been met and the allegation listed above is therefore SUBSTANTIATED.

Exit interview conducted with Licensees. A type B deficiency was cited.
NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20220217145356
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: FAN, LANA & ZHANG, XIAO MING
FACILITY NUMBER: 434413666
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2022
Section Cited
CCR
102416.2(b)(1)
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Reporting Requirements: The licensee shall report to the Department any of the events as specified in Health and Safety Code Sections 1597.467(b)(1)(A) through (b)(1)(C) that occur during the operation of the family child care home. (1) Medical treatment means treatment by a medical professional, as defined in Section 101152(m).
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Licensees agreed to submit UIR report (LIC 624B) to the office prior to the POC due day.
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This requirement is not met as evidenced by: Based on record review, licensees did not comply with the section cited above for reporting requirement which posed an 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.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3