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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407206
Report Date: 04/06/2022
Date Signed: 04/06/2022 12:24:19 PM


Document Has Been Signed on 04/06/2022 12:24 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:PHONGSA, YUNLIFACILITY NUMBER:
073407206
ADMINISTRATOR:PHONGSA, YUNLIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 218-2388
CITY:SAN RAMONSTATE: CAZIP CODE:
94582
CAPACITY:14CENSUS: 3DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Yunli PhongsaTIME COMPLETED:
12:23 PM
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On 4/6/2022 at 10:40am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Yunli Phongsa for an Unannounced Annual Inspection. Present during the inspection was the Licensee, three (3) preschool age children, and her three (3) children who were home on Spring Break, age 19, 17 and 15. Licensee’s home was toured for a health and safety inspection. The facility operates 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: Downstairs Bedroom

The facility is a two-story home owned by the Licensee. The inside and outside of the home were 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. Licensee has stated that there are no firearms and no pets in the home.

The home has one (1) fully charged 3A40BC fire extinguisher 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. LPA did not observe any harmful bodies of water in or around the home.


Continued on LIC809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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 5


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: 04/06/2022
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The Licensee’s Health and Safety training has been completed. Pediatric CPR and First Aid training was taken online in 2021 but was never issued proof of completion. LPA Pringle advised Licensee to retake the training in person (See LIC9102TV). Licensee’s Mandated Reporter training in “General Training” is complete. Licensee must renew the “Child Care Providers” (See LIC9102TV). All required forms are posted and visible for public in the living room. Fire/disaster drill log has not been completed as the three (3) children currently enrolled have only been in care for one (1) month. Licensee has five (5) more months to complete a fire/disaster drill. LPA obtained the children’s files and facility roster. All files were complete.

Licensee was reminded that California Law requires Licensee 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 two (2) years by visiting http://www.mandatedreporterca.com.

Licensee 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. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing.

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.


Continued on LIC809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: 04/06/2022
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To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee was 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 Licensee 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 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.


Exit interview conducted and report was reviewed with Licensee Yunli Phongsa.

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

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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