073407206-4-26-2023-52-CC-MPRE-CR9PPS-20230426113001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073407206
Report Date: 04/26/2023
Date Signed: 04/26/2023 11:30:15 AM

Document Has Been Signed on 04/26/2023 11:30 AM - 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, YUNLI		FACILITY NUMBER:	073407206
ADMINISTRATOR:	PHONGSA, YUNLI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(925) 218-2388
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94582
CAPACITY:	14	CENSUS: 3	DATE:	04/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Yunli Phongsa		TIME COMPLETED:	11:29 AM

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 4/26/2023 at 9:20am Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Yunli Phongsa for a Required - 1-Year Inspection. Present during the inspection was the Licensee, and three (3) preschool age children. Licensee lives in the home with her husband Bounpheth Phongsa, their adult daughters Jessica Phongsa and Olivia Phongsa, and sixteen (16) year old son. Licensee’s home was toured for a health and safety inspection. The facility operates from 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: Entire 2^nd Floor and Garage ISOLATION AREA: Downstairs Bedroom The facility is a two-story home owned by the Licensee. The inside of the home was observed to be 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 stated that she provides all food for the children. All food that is brought from the children’s home will be properly labeled and stored. Licensee stated that she does not transport children. There are no firearms and one (1) cat in the home.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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: PHONGSA, YUNLI	FACILITY NUMBER: 073407206
	VISIT DATE: 04/26/2023

NARRATIVE

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There is one (1) fully charged 3A40BC fire extinguisher located in the garage. There is one (1) working carbon monoxide detector at the bottom of the stairs across from the dining room. There are working smoke detectors in the living room, at the bottom of the stairs, in the downstairs bedroom and in the hallways between the bedroom and the garage. The electric fireplace in the living room is locked and does not get hot to the touch, making it inaccessible to the children in care. All napping equipment is clean and well maintained. All children provide their own sleeping materials from home. The home is equipped with central heat and air for proper ventilation. The backyard is fully fenced and has ample materials for the children in care. There are two (2) storage sheds on the right side of the home that are gated off and locked making them inaccessible to the children. LPA did not observe any harmful bodies of water in or around the home.

Licensee is operating within their licensed capacity and is in ratio. Licensee’s Health and Safety training has been completed. Licensee stated their pediatric CPR & First Aid certificate of completion is online. Licensee will send LPA proof of completion once found. If certificate cannot be found LPA has required Licensee to repeat the training. Licensee’s Mandated Reporter training is complete and expires 6/24/2023. LPA obtained the fire/disaster drill log, log is complete with the last drill logged 11/23/2022. At 10:10am through record review it was found Licensee’s daughter Olivia Phongsa has just turned eighteen (18). LPA informed Licensee that she will need to obtain a criminal record clearance. All other adults living in the home have obtained a criminal record clearance. All required forms are posted in the living room. 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. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.
Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. 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

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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: PHONGSA, YUNLI	FACILITY NUMBER: 073407206
	VISIT DATE: 04/26/2023

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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.

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.

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.

A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
Exit interview conducted and report was reviewed with Licensee Yunli Phongsa.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan Pringle	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

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