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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407206
Report Date: 06/17/2021
Date Signed: 06/17/2021 01:01:31 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:PHONGSA, YUNLIFACILITY NUMBER:
073407206
ADMINISTRATOR:PHONGSA, YUNLIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 218-2388
CITY:SAN RAMONSTATE: CAZIP CODE:
94582
CAPACITY:14CENSUS: 5DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Yunli PhongsaTIME COMPLETED:
01:00 PM
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On 6/17/2021 at 10:35am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Yunli Phongsa for an unannounced annual inspection. Present during the inspection was licensee Yunli Phongsa. Licensee lives with her fingerprint cleared husband Boun Phongsa and three (3) children ages 13, 15, 17. There are five (5) preschool children present today. Licensee stated the she does not have files for three (3) children as "they are here just for the day.” The Licensee’s home was toured for a health and safety inspection. The operating hours are 7:00am – 5:00pm Monday – Friday.

ON LIMITS AREA: Living Room, Family Room, Kitchen, Dining Room, Nook, Downstairs Bedroom, Downstairs Bathroom, and Backyard


OFF LIMITS AREA: Staircase, Garage, and entire 2nd floor
ISOLATION AREA: Bedroom

The facility is a two-story home owned by the Licensee. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children that are safe and clean. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there are no firearms and no pets.

The home has one (1) fully charged 3A40BC fire extinguisher located in the garage. One (1) working carbon monoxide detector in the dining room next to the bottom of the stairs, and one (1) smoke detector in the living room, dining room, downstairs bedroom, and the hallway between the bedroom and garage. The electric fireplace in the living room is locked and disconnected and inaccessible to the children in care. The home is equipped with central heating and air for proper ventilation. LPA observed no bodies of water in or around the home.

Cont on 809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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: PHONGSA, YUNLI
FACILITY NUMBER: 073407206
VISIT DATE: 06/17/2021
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At 11:15am LPA obtained the facility roster and requested the files for two (2) children. The Licensee’s Health and Safety training has been completed and CPR and First Aid training was taken but Licensee stated that she has not yet been issued a certificate of completion. Licensee provided the disaster/fire drill log as well. Last drill was completed on 2/01/2021 at 3:15pm.

All required forms are posted and visible for public view in the living room. Children’s files were reviewed. One (1) file is complete and one (1) file is incomplete.

Licensee 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 Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed 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.



Incidental Medical Services (IMS) policy was discussed as well. Licensee was reminded that when any IMS is provided, an updated Plan of Operation that includes IMS must be submitted to the Department. The following information 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.

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 $3,000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.

Cont on 809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
Page: 2 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: PHONGSA, YUNLI
FACILITY NUMBER: 073407206
VISIT DATE: 06/17/2021
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Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six months and documented. The licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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

This report was read and given to the Licensee for a signature. There are no deficiency being cited today. This report shall remain on file for 3 years. Appeal Rights were provided and exit interview conducted. A Notice of Site visit was given at the time of inspection and must be posted for 30 days.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
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