015700220-9-13-2021-52-CC-LDBX-C6TUQA-20210913154648

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015700220
Report Date: 07/27/2021
Date Signed: 09/13/2021 03:46:57 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:	CHHON, NARY		FACILITY NUMBER:	015700220
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 5	DATE:	07/27/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Nary Chhon		TIME COMPLETED:	01:50 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 July 27, 2021 at approximately 12: 45 PM Lorraine Dacanay Breaux, Licensing Program Analyst, (LPA) met with Licensee Nary Chhon to conduct an Unannounced Case Management Inspection for an Increase of Capacity. There was 5 (five children) in care during this inspection. Ages 8 years old, 2 children ages 3 years old, 1 child 2 years old and 1.5 year old child. LPA and Licensee toured the home to conduct a Health and Safety Inspection. The facility currently operates Monday through Friday, 8:30 AM until 5:30 PM. The home is neat and clean with heating and ventilation for safety and comfort. Description of Home: The residence is a two story; which consist of 4 bedrooms, 3 bathrooms, large open entryway, living room, children's playroom, kitchen, dining room, backyard and attached garage. Off Limit Areas: Entire Upstairs Level; which includes 4 bedrooms, 2 bathrooms, laundry room and garage. On Limit Areas: Open entryway, dining room, playroom to the left of home, living room, bathroom, and backyard. Isolation Areas: Playroom and/or living room to the left of home. There are age appropriate furnishings, toys and equipment in the playroom, entryway, living room and backyard. The stairway has child safety gating at the base of the stairs. There is an additional gate leading to the living room. There is a fireplace in the living room which is screened and an additional barrier to prevent access by children in care. See 809-C

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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: CHHON, NARY	FACILITY NUMBER: 015700220
	VISIT DATE: 07/27/2021

NARRATIVE

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There are multiple combo smoke detectors/carbon monoxide detectors present and working. The facility has a fully charged 2A10BC fire extinguisher. A fire clearance was granted on 7/13/2021 by the Dublin Fire Prevention Services noting (No children on second floor). The bathroom has working toilet and faucet in new condition.
Per licensee, there are no firearms on the premises.The home has a fully fenced back yard area. There are no pools, hot tubs or other accessible bodies of water observed today. Hazardous items/cleaning supplies are stored inaccessible to children in care. All electrical outlets have safety covers.

The Licensee Health and Safety training is completed (lead exposure included), CPR and First Aid certificate is current and expires 08/27/2022. The applicant completed and received a certificate in mandated reporter training on 01/26/2021. The applicant is following the immunization laws which pertains to all day care providers. A copy of the lease agreement was reviewed.

LPA reminded applicant of the following; Mandated Reporter training is to be renewed every two years. CPR/First Aid is also renewed every two years. Baby bouncers & drop-down cribs are not allowed at the day-care facility. LPA discussed Unusual Incidents Report.

Applicant 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. Applicant was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

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: CHHON, NARY	FACILITY NUMBER: 015700220
	VISIT DATE: 07/27/2021

NARRATIVE

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Recommendations:
Remove the Aloe Vera Plants in the yard (two)
Add a gate to separate the side yard, drains have a cover, yet the depth is hazard to a child in care and trip hazard on the left side of home facing the rear of the house. Licensee will send photos when completed, Licensee state she will add a gate and hazard cones as a safety prevention.

This facility is approved for the Increase of Capacity effective today 7/27/2021.

A copy of this report was provided to licensee and is to remain in the facility records for a period of three years. A notice of site visit was also provided and is required to be posted for 30 days.

Exit Interview Conducted.

SUPERVISOR'S NAME: Chandra Charles	TELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Lorraine Dacanay-Breaux	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2021

LIC809 (FAS) - (06/04)

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