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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414205
Report Date: 05/03/2019
Date Signed: 05/03/2019 04:10:14 PM

COMPREHENSIVE INSPECTION
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:NGUYEN, TRA THI & TRUONG, SON NHUTFACILITY NUMBER:
434414205
ADMINISTRATOR:NGUYEN, TRA THIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 386-2045
CITY:SAN JOSESTATE: CAZIP CODE:
95132
CAPACITY:14CENSUS: 9DATE:
05/03/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Tra NguyenTIME COMPLETED:
04:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuoc Doan conducted an unannounced Annual Inspection of the Family Child Care Home. LPA met with Licensee Tra Nguyen and explained the purpose of the inspection. When LPA arrived at the home, Licensee was alone caring for eight children. Since there was no second care provider present, the home shall comply with the requirements of a Small Family Child Care Home. That is, when there is only one Care Provider present, the home can have more than six and up to eight children if at least one child is attending school and one child is at least six years old. None of the eight children present upon LPA's arrival are school age or at least six years old.

Therefore, the home was not in compliance with the capacity requirement until Licensee's Assistant Provider Tien Le came to the house approximately 20 minutes after LPA had arrived.

The home’s operating days and hours are Monday through Saturday from 7:00 AM to 9:00 PM. The day care maintains telephone service. Facility’s License and Notification of Parents’ Rights were observed to be posted. The home was inspected inside and out. The home was clean and orderly, with heating and ventilation for the safety and comfort of children in care. LPA did not observe flies, other insects, and rodents during the inspection. The fireplace was screened to prevent access by children. The observed children’s toys, play equipment and materials were safe and age appropriate. Furniture and equipment, such as play pen and mats were age appropriate and in good condition. There were no baby walkers observed to be in used. Bathroom used by children was observed to be sanitary and in operating condition.

Off limit areas in the home are: the whole second floor and garage. There is a child safety gate installed at the base of the stair case to prevent children from accessing the stairs to the second floor. The backyard is fenced and is used for outdoor activity. There were no bodies of water observed. Licensee stated that there were no weapons stored on the premises.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
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 7
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: NGUYEN, TRA THI & TRUONG, SON NHUT
FACILITY NUMBER: 434414205
VISIT DATE: 05/03/2019
NARRATIVE
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A fully charged fire extinguisher was observed. Carbon monoxide and Smoke Detectors were tested and proved to be functioning. Fire and Disaster drill was last conducted on 02/20/18. The Licensee stated that she does transport children at this time. Licensee has a current and valid driver license. Licensee understands that children cannot be left in parked vehicles unattended at any time, the motor vehicles used to transport children in care shall be maintained in safe operating conditions, and all vehicle occupants must be secured in an appropriate restraint system.

LPA reviewed the roster of children in care. Children’s files were reviewed, which included records of Identification and Emergency Information, Consent for Medical Treatment, receipt for Parents' Rights Notice, and Immunization. Safe sleep information was reviewed with Licensee.

Licensee and the Assistant Provider Tien Le files were reviewed, which included records of Criminal Record and Child Abuse Index Clearance, TB clearance, Statement Acknowledging Requirement to Report Suspected Child Abuse, Immunization record for Measles and Pertussis, and required Training. Licensee Pediatric CPR and First Aid certification expires 03/2020. Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors, and employees to complete training as specified on their mandated reporter duties. Licensee has informed Licensing Office that she will complete the Training once a Vietnamese version of the training becomes available.

Adults who are over the age of 18 and reside in the home are the Licensee and Licensee's spouse. They have Clearance for Criminal Record and Child Abuse Index Background Check, and Tuberculosis.
LPA reminded Licensee 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. For an initial violation, civil penalty amounts to $100.00 per person per day up to $500.00 per person. For a subsequent violation within a 12-month period, civil penalty amounts to $100.00 per person per day up to $3000.00 per person.

LPA also reviewed with Licensee the violations that would result in an immediate assessment of civil penalty in the amount of $500. Licensee is encouraged to visit the Department’s website at www.cdss.ca.gov [Shortcut: www.ccld.ca.gov] to access resources for Providers, Regulations, Online option to pay Annual License fee, Adoption of new Laws, etc.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: NGUYEN, TRA THI & TRUONG, SON NHUT
FACILITY NUMBER: 434414205
VISIT DATE: 05/03/2019
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. The Licensee stated that she currently does not have any children in care who requires IMS. 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.

In the areas that were evaluated, regulatory violations were observed at the time of the visit. Therefore, Type A and B citations were issued. Exit Interview was conducted, where this report, the Citations, Plan of Corrections, and Appeal Rights were reviewed and discussed with Licensee in English and Vietnamese.

Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent and to the parent of children who are enrolled over the next 12 months. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and be kept in each child's file.

This report and a copy of the LIC 9224 form was provided to Licensee at the conclusion of the inspection.

A NOTICE OF SITE VISIT and THIS LICENSING REPORT were issued and must be POSTED on or adjacent to the interior side of the main door into the facility FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: NGUYEN, TRA THI & TRUONG, SON NHUT
FACILITY NUMBER: 434414205
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2019
Section Cited
CCR
102418(g)
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IMMUNIZATION. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
This requirement is not met as evidenced by:
Based on LPA's review of files, facility did not have a copy of the immunization records for Child 1, 2 , 3 and 4 during inspection. This
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BY POC DUE DATE, 05/13/19, Licensee agreed to obtain and maintain a copy of the immunization record for Child 1, 2, 3, and 4. A copy will be sent to Licensing Office to show proof of correction.
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potential risk to the health and safety of children in care.
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Type B
05/13/2019
Section Cited
CCR
102421(a)
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CHILD RECORDS. The licensee shall maintain, in each child’s record, the signed and dated notice form LIC 995A, Parents Rights Notice.
This requirement is not met as evidenced by:
Based on LPA's review of files, Child 4 and 5 do not have the signed form LIC 995A
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BY POC DUE DATE, 05/13/19, Licensee agreed to obtain a signed and dated receipt of Parents Rights Notice from the parent of Child 4 and 5. A copy of the signed form will be sent to Licensing Office to show proof of correction.
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"Parents' Rights Notice" on file during the inspection. This poses a potential risk to the health and safety of children in care.
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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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: NGUYEN, TRA THI & TRUONG, SON NHUT
FACILITY NUMBER: 434414205
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2019
Section Cited
CCR
102417(g)(7)
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OPERATION OF A FAMILY CHILD CARE HOME. An emergency information card shall be maintained for each child [...] and the parent's authorization for the licensee or registrant to consent to emergency medical care.
This requirement is not met as evidenced by:
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LPA went over the Licensing forms with Licensee:
1) LIC700 Identification and Emergency Info.
2) LIC627 Consent for Emergency Medical Treatment.

BY POC DUE DATE, 05/13/19, Licensee
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Based on LPA's review of the files during inspection, Child 4 is missing a completed form LIC627 and form 700, This poses a potential risk to the safety of children in care.
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agreed to obtain the above forms from Child 4's parent. A copy of the forms will be sent to Licensing Office to show proof of correction.
Type B
05/13/2019
Section Cited
HSC
1596.841
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HEALTH & SAFETY CODE: Each child day care facility shall maintain a current roster of children who are provided care in the facility. The roster shall include the name, address, and daytime telephone number of the child's parent [...], and the name and telephone number of the child's physician.
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BY POC DUE DATE, 05/13/19, Licensee agreed to update the Roster of children who are provided care at the facility. A copy of the current roster will be sent to Licensing Office to show proof of correction.
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Based on LPA's review of the roster and files for children in care, there are at least three children who are present during LPA's inspection but are not listed on the roster. This poses a potential risk to the health and safety of the children in care.
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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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
LIC809 (FAS) - (06/04)
Page: 6 of 7
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: NGUYEN, TRA THI & TRUONG, SON NHUT
FACILITY NUMBER: 434414205
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2019
Section Cited
CCR
102416.5(e)
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STAFFING RATIO AND CAPACITY. If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
This requirement is not met as evidenced by:
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Assistant Provider Tien Le came to the day care home approximately 20 minutes after LPA had arrived. Per Licensee and Tien Le, Tien Le works part time, approximately 4 hours a day. Tien Le stated that this week she works from around 01:30 PM to 05:00 PM. LPA explained to Licensee about the capacity
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When LPA entered the home, Licensee was alone by herself and caring for 8 children. None of the 8 children were enrolled in school and none were at least 6 years old. Licensee operated beyond the capacity limitation. This poses an immediate risk to the health and safety of children in care.
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requirement of the child care home.

BY POC DUE DATE, which is Monday, 05/06/19, Licensee will submit to Licensing Office a plan of action detailing how Licensee will ensure that she complies with the staffing ratio and capacity requirement.
Type A
05/06/2019
Section Cited
CCR
102417(g)(4)
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OPERATION OF A FAMILY CHILD CARE. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger to children shall be stored where they are inaccessible to children.
This requirement is not met as evidenced by:
LPA observed cleaning compounds stored
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During inspection, Licensee immediately removed the cleaning compounds from under the Kitchen sink and stored them on higher shelving that are out of reach of children in care.

BY POC DUE DATE, which is Monday 05/06/19, Licensee will install a lock on the
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under the Kitchen sink. Sharp tools and chemicals were stored in storage shed and cabinet in the back yard. These hazardous items were accessible to children as they were within reach of the children in care. This poses an immediate risk to the health and safety of children in care.
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doors of the storage shed and cabinet in the backyard to keep the children from accessing the hazardous materials stored inside. Licensee will send to Licensing Office a picture of the installed lock as proof of correction.
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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: NGUYEN, TRA THI & TRUONG, SON NHUT
FACILITY NUMBER: 434414205
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2019
Section Cited
CCR
102417(g)(9)
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OPERATION OF A FAMILY CHILD CARE HOME. Each family child care home shall conduct fire drills and disaster drills at least once every six months. The licensee shall document the drills, including the date and time of each drill.
This requirement is not met as evidenced by:
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BY POC DUE DATE, 05/13/19, Licensee agreed to conduct Fire and Disaster drills and document the date and time. A copy of the updated Drill log will be sent to Licensing Office to show proof of correction.
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Per Licensee and Facility's Fire Drill Log, the last drill was conducted on 02/20/18, which has been more than 6 months ago. This poses a potential risk to the health and safety of children in care.
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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: Sandy KnightTELEPHONE: (408)324-2151
LICENSING EVALUATOR NAME: Tuoc DoanTELEPHONE: (408) 497-7322
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2019
LIC809 (FAS) - (06/04)
Page: 7 of 7