304312564-10-2-2019-06-CC-THOO-BGKUQN-20191002154725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304312564
Report Date: 10/02/2019
Date Signed: 10/02/2019 03:47:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	DUONG, PHUONGDUNG		FACILITY NUMBER:	304312564
ADMINISTRATOR:	DUONG, PHUONGDUNG		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 414-9948
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY:	14	CENSUS: 4	DATE:	10/02/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Licensee Phuongdung Duong		TIME COMPLETED:	04:15 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	This inspection conducted in Vietnamese. Licensing Program Analyst (LPA) and licensee toured the facility inside and outside. LPA observed 2 infants and 2 school-age children napping in the day care area. The facility was within licensed capacity and the required ratio. Licensee stated no other adults were living at the facility. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. This is a single, story home with 3 bedrooms and 2 baths. Family members residing at facility are 4 adults and no children. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children. Per Licensee there are no weapons, firearms in the facility at this time. Anytime when firearms were present in the facility, they must be locked and inaccessible to children. The ammunition must be locked and separate from the firearms. No *swimming pool, spa or other bodies of water observed on the premises. There are age appropriate toys and equipment on the premises. The required fire extinguisher (2A10BC), carbon monoxide, and smoke detectors are in operable condition. The toys appeared age appropriate and in good condition for the ages served. Facility roster, disaster drill, and licensee’s required immunization (MMR, TDAP, FLU) were available for review. The licensee was reminded that must present at facility and ensure that children are properly cared for and supervised at all times. The licensee must make sure that a substitute adult cares for the children when licensee is temporarily absent. The licensee was also reminded that no child shall be left alone in a parked vehicle at any time. All day-care activities take place in the kitchen, family room, the two bedrooms on the left side of the hallway, and living room. Children are able to have outside play in the enclosed backyard. Licensee is current with Pediatric CPR and First Aid and both valid until 11/22/20.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy Ho	TELEPHONE: (714) 296-6577
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2019

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: DUONG, PHUONGDUNG	FACILITY NUMBER: 304312564
	VISIT DATE: 10/02/2019

NARRATIVE

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Licensee does not provide IMS to children.

The following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to presence in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, no infant walkers, No Johnny jumpers, no exersaucer or any other similar items that fall into that category are allowed in the facility. Disaster drills, posting requirements, children records, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby.

After a tour of the home and review children and staff's records, no deficiency was observed.

During exit interview, “The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.” Notice of Site Visit was posted. Licensee was informed to keep the Notice of Site Visit posted for 30 days during the day care hours or $100 civil penalty will be assessed.

Licensee was informed that the CRIMINAL RECORD STATEMENT (LIC 508) has been updated, and the facility must now use the new form with revised date 7/15. Licensee was also informed that the LIC 508 must be submitted with all Criminal Background Clearance Transfer Request (LIC9182).

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The licensee was informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org and a copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy Ho	TELEPHONE: (714) 296-6577
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2019

LIC809 (FAS) - (06/04)

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