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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 434416263
Report Date: 12/21/2021
Date Signed: 12/21/2021 12:42:45 PM

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
12/20/2021 and conducted by Evaluator Yangcheng Huang
PUBLIC
COMPLAINT CONTROL NUMBER: 07-CC-20211220094547
FACILITY NAME:BI, XIAOWENFACILITY NUMBER:
434416263
ADMINISTRATOR:XIAOWEN BIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 508-0471
CITY:SANTA CLARASTATE: CAZIP CODE:
95051
CAPACITY:14CENSUS: 1DATE:
12/21/2021
UNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Xiaowen BiTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Adult caring for children does not have proper qualifications
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 Licensee, Xiaowen Bi, and discussed the above allegation with her. LPA also observed licensee's mother and her school age child. LPA interviewed licensee, and copies of pertinent documents were also obtained.

Based on interview of Licensee and 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 Licensee, Xiaowen Bi, and informed her that AB633 Parent Notification is required. According to AB 633, all parents of children currently enrolled and any future children being enrolled for the next 12 months must be provided with this report which contains this Type A deficiency.

NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED with Type A Deficiency Report FOR 30 DAYS.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Yangcheng Huang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
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-20211220094547
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: BI, XIAOWEN
FACILITY NUMBER: 434416263
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2021
Section Cited
CCR
102370(d)(2)
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Criminal Record Clearance: (d) 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.
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Licensee agreed to have the helper taking and completed the live scan by the POC due day.
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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 helper which posed an immediately health, safety or personal rights risk to persons in care.
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AB633 Parent Notification is required. According to AB 633, all parents of children currently enrolled and any future children being enrolled for the next 12 months must be provided with this report which contains this Type A deficiency.
Type A
01/21/2022
Section Cited
CCR
102416(C)
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Personnel Requirements: The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
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Licensee agreed to have either herself renewing the CPR/First Aid training and/or the helper taking and completed the live scan by the POC due day.
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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 helper who was alone to care children without CPR/First Aide certified which posed an immediate health, safety or personal rights risk to persons in care.
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AB633 Parent Notification is required. According to AB 633, all parents of children currently enrolled and any future children being enrolled for the next 12 months must be provided with this report which contains this Type A deficiency.
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: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3