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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013420636
Report Date: 03/29/2022
Date Signed: 03/29/2022 03:14:38 PM


Document Has Been Signed on 03/29/2022 03:14 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:TIET H DOFACILITY NUMBER:
013420636
ADMINISTRATOR:TIET H DOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 589-5042
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:14CENSUS: 11DATE:
03/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Tiet H Do- LicenseeTIME COMPLETED:
03:30 PM
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On 3/29/22 at 2:00pm, 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 son Tyler Do, 7 preschool age children, and 4 school age children. 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 3/13/23. 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 2/3/22.
At 2:20pm, 5 Children files were reviewed and at 2:27pm, licensee provided LPA Plumboy with a copy of her facility roster. The licensee, her mother/assistant Huong Nguyen, and daughter Diana Do are in compliance with the immunization law. Licensee and daughter/assistant Diana Do received certificates in mandated reporter training on 1/11/21 and Huong Do currently has a waiver on file for mandated reporter training until it is available in Vietnamese. 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 NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2022
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: 03/29/2022
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Incidental 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
Per licensee there are no children who require IMS at this time

Licensee was encouraged to frequently visit our website at ccld.ca.gov for licensing regulations and updates.

Licensee is reminded that ALL assistants, volunteers, and staff, 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



LPA discussed the safe sleep regulations with licensee Tiet H Do and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee Tiet H Do of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

A notice of site visit was given and must remain posted for 30 days.

No deficiencies cited during today's inspection. Appeal rights provided and discussed. Exit interview conducted and report was reviewed with licensee Tiet H Do.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2