434407732-5-22-2019-07-CC-MSMS-BCENFL-20190522102544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434407732
Report Date: 05/22/2019
Date Signed: 05/22/2019 10:25:51 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	JAN, MAAN MEY		FACILITY NUMBER:	434407732
ADMINISTRATOR:	JAN, MAAN MEY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 300-5997
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95131
CAPACITY:	14	CENSUS: 10	DATE:	05/22/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Maan Mey Jan & Chuan Xiao		TIME COMPLETED:	10:30 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) Mel Matos met with Maan Mey Jan, Licensee, for an unannounced annual/random inspection. LPA also observed Licensee's spouse, two adult assistants (Chuan Xiao & Jiefang Liu), and ten day care children (4 infants & 6 preschool) in the home during today's inspection. Chuan Xiao, adult assistant, helps the Licensee with the overall administration and operation of the day care. Days and hours of operation are Monday - Friday from 8:30 AM to 6:00 PM. The Licensee and her spouse are the adults residing in the home. The Licensee's certifications for CPR and First Aid are current and expire on August 26, 2019. Licensee's two adult assistants have current CPR & First Aid certifications (expire: 02/02/2021). LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Last fire/disaster drill was completed on April 15, 2019. LPA observed that the Licensee and two adult assistants has the required immunization record on file. The two adult assistants have completed the required Mandated Reporter Training for Child Care Workers. The Licensee is exempt from the Mandated Reporter training LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters inside the home. LPA observed barricaded stairs during today's inspection. Off limit areas in the home (upstairs): master bedroom, master bathroom, two bedrooms, and one bathroom. Off limit areas in the home (downstairs): one barricaded fireplace (located in the living room), and attached garage. Off limit areas outside the home: left side of the backyard, barricaded air conditioner unit, and one locked storage shed. LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. The Licensee states that she does not have any weapons or pets in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 05/22/2019):

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: JAN, MAAN MEY	FACILITY NUMBER: 434407732
	VISIT DATE: 05/22/2019

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/22/2019):

A review of staff records on May 21, 2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded the Licensee & Chuan of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time with at least two qualified adults present. The Licensee states that she does not transport any day care children. The Licensee states that she is not administering any medication at this time.

Website for provider resources & licensing updates: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

No deficiencies issued during today's inspection.

LPA conducted an exit interview with the Licensee & Chuan Xiao prior to the conclusion of today's inspection and requested that an updated Emergency Disaster Plan (LIC 610A) be submitted to LPA Matos by Friday May 31, 2019.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Mary Segura	TELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2019

LIC809 (FAS) - (06/04)

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