434412847-12-4-2019-07-CC-DMAC-BJJVYK-20191204155115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434412847
Report Date: 12/04/2019
Date Signed: 12/04/2019 03:51:37 PM

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:	TO, PHUONG TRAM		FACILITY NUMBER:	434412847
ADMINISTRATOR:	TO, PHUONG TRAM		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 600-4553
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95122
CAPACITY:	14	CENSUS: 13	DATE:	12/04/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	To, Phuong Tram		TIME COMPLETED:	04:00 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	LPA, Dung Mac, met with Phuong Tram To, Licensee, and explained the purpose of today’s inspection. LPA observed two Assistants, DieuAnh Nguyen, and Nhan Do, and thirteen daycare children of whom were three infants, eight preschoolers, and two school-ages during today's inspection. Days and hours of operation are Monday-Friday 7:30am-6:00pm. LPA toured the inside and outside of the home. Off limit areas inside the home are master bedroom, bedroom #2, bedroom #1, garage, backyard, and right side of the home. Backyard is fenced and has gates. Part of the fence is broken. Licensee stated that children are not playing in the backyard until the broken fence is fixed. LPA observed that there are no bodies of water. LPA observed a fully charged fire extinguisher, working smoke detector and carbon monoxide. Licensee stated that there are no weapons in the home. Licensee has fish tank located in the living room. LPA observed fireplace is screened. Cleaning products, toxic, medications, and sharp objects were inaccessible to children. The home is clean, orderly, and safe for the day care children. LPA observed sufficient materials, toys, and play equipment for the day care children. Licensee stated that she sometimes transports children. LPA reminded Licensee that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children shall be maintained in safe operating conditions, and all vehicle occupants must be secured in an appropriate restraint system. The last Fire/Disaster drills was conducted on 11/4/19. LPA reminded Licensee that Fire/Disaster Drills must be done at least once every 6 months. LPA reviewed the Child Care Facility Roster. Twelve children's files were reviewed and all are complete. A review of records on 12/4/19 shows that all staff and other adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Adults who reside in the home are Licensee, Licensee's spouse, and roommate. Roommate did not have Clearances for Tuberculosis. Continued on Page #2

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019

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 3

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: TO, PHUONG TRAM	FACILITY NUMBER: 434412847
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/04/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/30/2019 Section Cited	1 2 3 4 5 6 7	Immunization Requirements: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by Licensee and Assistants had not been immunized against measles which poses a potential Health, Safety, or Personal risks to daycare children.	8 9 10 11 12 13 14
Type B 12/30/2019 Section Cited	1 2 3 4 5 6 7	Evidence of a current tuberculosis clearance, not more than one year prior to or seven days after initial presence in the home, for any adult in the home during the time that children are under care.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by a roommate did not have TB test which poses a potential Health, Safety, or Personal risks to daycare children.	8 9 10 11 12 13 14

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: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3

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: TO, PHUONG TRAM	FACILITY NUMBER: 434412847
	VISIT DATE: 12/04/2019

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Continued from Page #1

Licensee and Assistant Providers' files were reviewed. They did not have records of Measles immunization. Assistant, Nhan Do, has not taken the Mandated Reporter Training as Vietnamese is her primary language. Licensee's Mandated Reporter training expires 2/11/20 and his Pediatric CPR & First Aid certification expires 10/20. LPA reminded Licensee that the Mandated Reporter Training needs to be renewed every two years.

Facility's Incidental Medical Services (IMS) policy was discussed. Licensee stated that she currently does not have any children in care who requires IMS. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) and link to Commonly Asked Questions and the ADA, available at:<http://www.ada.gov/childqanda.htm> .

LPA provided a copy of the “Lead Poisoning Facts Information Flyer”, "Car Seat Law", and "Safe Sleep" Information to Licensee.

Type B deficiencies were cited today. An exit interview was conducted. Appeal Rights were given to Licensee. Notice of Site Visit was given to Licensee and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Dung Mac	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019

LIC809 (FAS) - (06/04)

Page: 2 of 3