<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700339
Report Date: 05/09/2022
Date Signed: 05/09/2022 12:45:24 PM

Document Has Been Signed on 05/09/2022 12:45 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:NGUYEN, HOAFACILITY NUMBER:
015700339
ADMINISTRATOR:NGUYEN, HOAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 443-8188
CITY:HAYWARDSTATE: CAZIP CODE:
94545
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
05/09/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Hoa NguyenTIME COMPLETED:
12:42 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 5/9/2022 at 11:00am Licensing Program Analyst (LPA) Morgan Pringle met with applicant Hoa “Lisa” Nguyen for an Announced Pre-Licensing Visit. Present during the inspection was the applicant and her husband. Licensee lives in the residential home with her husband and two (2) minor children, age sixteen (16) and nine (9). The applicant’s home was then toured for a health and safety inspection. The facility plans to operate from 7:30am – 6:00pm Monday – Friday.

The facility is one (1) of four (4) buildings on the Applicants property. First, there is the “off limits” three (3) bedroom two (2) bathroom home that the applicant lives in. Second, an “off-limits” triplex rental property; unit one (1) is a two bedroom, two (2) bathroom, unit two (2) is a two (2) bedroom, one (1) bathroom, and unit three (3) is one (1) bedroom one (1) bathroom. Third, there is a large shed being built on the property. Fourth, the building used for childcare. The childcare building consists of two rooms, Room one (1) and Room two (2), and two bathrooms.

ON LIMITS AREA: Childcare Building and Back Yard
OFF LIMITS AREA: Residential Home and Front Yard, Triplex Rental Property, Outside Shed
ISOLATION AREA: Childcare Area: Room Two (2)

The inside and outside of the childcare building are observed to be neat, clean with ample age appropriate materials for the children. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Applicant has stated that there are no firearms and no pets on the property.

Facility received a fire clearance on 4/22/2022 from the Hayward Fire Department.

Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: NGUYEN, HOA
FACILITY NUMBER: 015700339
VISIT DATE: 05/09/2022
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
26
27
28
29
30
31
32
There is a working smoke detector in both rooms of the childcare building. There is one working smoke/carbon monoxide detector above the main door. There are two (2) 2A10BC fire extinguishers and a pull-down alarm. The applicant’s Health and Safety training with the lead poisoning component has been completed and CPR and First Aid certificate is current and expires on 8/21/2023. Mandated Reporter training is complete and expires on 7/24/2023. All adults living on the property have obtained a criminal record clearance. The building is equipped with a wall heater that will be properly barricaded making it inaccessible to the children in care and plenty of windows for proper ventilation. Applicant provided proof of immunization for pertussis, measles, and the flu shot.

Applicant was reminded that California Law requires 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 email. LPA informed the applicant that all forms can be downloaded at www.ccld.ca.gov. Applicant was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Applicant was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. Applicant is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.
Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important
Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.


Continued on LIC809-C
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: NGUYEN, HOA
FACILITY NUMBER: 015700339
VISIT DATE: 05/09/2022
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
26
27
28
29
30
31
32
Applicant reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with Applicant 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 Applicant 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.
LPA reviewed with Applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 reviewed with Applicant the LIC311D, Forms/Records To Keep In Your Family Child Care Home, Children’s Forms/Records, Facility Forms/Records, and Information to be Posted.

Entrance checklist was provided to the Applicant.

Exit interview conducted and report was reviewed with the Applicant Hoa “Lisa” Nguyen.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Morgan Pringle
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3