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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197418922
Report Date: 11/15/2019
Date Signed: 11/15/2019 11:54:13 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:PHAM FAMILY CHILD CAREFACILITY NUMBER:
197418922
ADMINISTRATOR:PHAM, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(424) 675-4403
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:14CENSUS: 8DATE:
11/15/2019
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Tina Pham, LicenseeTIME COMPLETED:
11:06 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
Licensing Program Analyst (LPA) Shandra Powell conducted a Case Management Incident inspection to follow up on the self reported incident that occurred at the Family Child Care home on 10/02/19. The El Segundo Regional Office received the incident report on 10/03/19. Upon arrival, LPA observed proper care and supervision. Licensee and Assistant were present during today’s inspection.

LPA observed incident report (ouch report), after visit summary from child's doctor visit and a copy of a report of notice of childcare incident or accident for licensees Insurance Company. LPA interviewed Staff 1 and Staff 2 during inspection. Based on the information that were gathered through interview and observation, it revealed that, on the day of the incident there were 3 children with 2 staff . While children were coming in from outside C1 tripped on the first step leading into the home at the back door and hit his forehead on the second step leading into the home. LPA observed the second step to be raised higher than first step. LPA observed the final step to made of concrete and to have a sharp edge. This poses a potential risk to the health and safety of children in care. When C1 tripped he fell and hit his forehead on the sharp edge of the step (photos taken). Staff 1 observed the fall and picked up child and immediately applied pressure to the visible gash in the middle of C1 forehead with hand to stop the bleeding. Parents were contacted. Child was taken to the doctor and stiches were required. Child has returned back to the child care home. To prevent other similar incident from reoccurrence, staff will hold hand of children when stepping up to come in or out of the back door. Staff will also place markers so children will not be close to one another when walking in or out of back door. At this time based on the interviews and observations it does appear this incident was the result of a Title 22 violation for personal rights however care and supervision were provided at all times. Deficiency cited on attached 809D.

Exit interview was conducted with Tina Pham, licensee, including, but not limited to Provider Rights, Appeal Procedures and Agencies Consultative Role. Notice of Site Visit form was posted and explained. The notice shall be posted for 30 days or a civil penalty of $100 shall be assessed.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Shandra PowellTELEPHONE: (323) 981-3383
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2019
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: PHAM FAMILY CHILD CARE
FACILITY NUMBER: 197418922
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/06/2019
Section Cited

1
2
3
4
5
6
7
Personal Rights
a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:
8
9
10
11
12
13
14
To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. The requirement was not met by evidence of LPA observing back step high and has a sharp edge where children in care can receive injuries.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Mary RuizTELEPHONE: (424) 301-3061
LICENSING EVALUATOR NAME: Shandra PowellTELEPHONE: (323) 981-3383
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2