013420636-3-4-2020-52-CC-BPLY-BMDUZN-20200304150149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013420636
Report Date: 03/04/2020
Date Signed: 03/04/2020 03:01:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	TIET H DO		FACILITY NUMBER:	013420636
ADMINISTRATOR:	TIET H DO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 589-5042
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	14	CENSUS: 13	DATE:	03/04/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:12 PM
MET WITH:	Tiet H Do- Licensee		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 3/04/20 at 2:12pm, Licensing Program Analyst Briana Plumboy met with licensee Tiet Do for an UNANNOUNCED ANNUAL REQUIRED INSPECTION. Present for this visit was fingerprint clear adult/assistant Huong Nguyen (licensees mother), licensee fingerprint clear and associated assistant/daughter Diana Do, licensee's fingerprint clear and associated husband Ty Do, 2 infants, 6 preschool age children, and 5 school age children. The home was toured to conduct a Health and Safety Inspection by LPA Plumboy and licensee Tiet H Do accompanied her on the inspection which was conducted upon LPAs arrival in the facility at 2:12pm. The operating hours for this facility are 7:00 am to 6:00 pm. The home is two levels. This is a 4 bedroom 3 bathroom home. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMITS areas are the kitchen, living room, family room, downstairs bathroom, and downstairs bedroom which is used as a nap room. The following areas are OFF LIMITS; The Entire second level of the home, the garage, and the shed in the backyard which will be inaccessible by closed and/or locked doors and visual supervision. There is a gate located at the bottom of the stairs during todays inspection to prevent access to children under the age of 5. The ISOLATION AREA will be the living room for an infant or preschool age child, and the family room for a school age child. The BACKYARD play area is fenced. There are 2 swing sets located in the backyard which are stable to the ground and cushioned underneath to absorb a fall. The living room has gates to physically separate children for age appropriate activities if needed. There are toys, play equipment, and learning materials. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today's inspection. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible to children in care during today's inspection. The home has a fully charged fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The licensee and Huong Nguyen's CPR and First Aid certificates are current and expires 11/03/2020. The fireplace is barricaded to prevent access by children. Per licensee, there are no firearms in the home. The licensee conducts and documents fire and disaster drills twice a year with the last one conducted on 10/03/19. At 2:32pm, 5 Children files were reviewed and at 2:44pm, licensee provided LPA Plumboy with a copy of her facility roster. The licensee is in ratio today. All REQUIRED forms are posted and visible for public review. See 809-C for continuance

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: TIET H DO	FACILITY NUMBER: 013420636
	VISIT DATE: 03/04/2020

NARRATIVE

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Individual Medical Services (IMS) policy was discussed. 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: http://www.ada.gov/childqanda.htm

LPA Plumboy provided a copy of Safe Sleep in Child Care brochure, a handout "What Does A Safe Sleep Environment Look Like?," and PIN 19-06-CCP to the licensee

LPA Plumboy provided licensee with a copy of the CDSS handout on Effects of Lead Exposure

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility. Licensee was reminded of Departments inspection authority, with our without any notice.

California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Roster of the children must be properly maintained and fire/disaster drill every six months must be documented.

The licensee was also reminded that baby bouncers, exersaucers, johnny jumpers and similar items are not allowed in licensed day care.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list

There are no deficiencies cited. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted.

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2020

LIC809 (FAS) - (06/04)

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