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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434414205
Report Date: 12/17/2019
Date Signed: 12/17/2019 11:29:29 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: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: 6DATE:
12/17/2019
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Tra Thi NguyenTIME COMPLETED:
11:35 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Tuoc Doan and Stephanie Collins conducted an unannounced visit to the day care home for a Case Management inspection. LPAs met with Licensee Tra Thi Nguyen and informed her of the inspection. LPAs observed present was Licensee providing care and supervision to six children, of whom three were under 2 years old. Licensee was operating in compliance with capacity and ratio requirement during the inspection.

LPAs inspected areas inside the home and backyard. Children's files were also reviewed.

In the areas that were evaluated, one regulatory violation was observed during the inspection.

LPA Doan conducted the exit interview in Vietnamese with Licensee. This report, the violation, plan of correction, and appeal rights were reviewed with Licensee.

A NOTICE OF SITE VISIT WAS 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: 12/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2019
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: NGUYEN, TRA THI & TRUONG, SON NHUT
FACILITY NUMBER: 434414205
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/03/2020
Section Cited

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HEALTH & SAFETY CODE. [...] A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation [...] The licensee shall keep verification of receipt
in each child's file.
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This requirement is not met as evidenced by:
Per LPA's review of children's files, Licensee failed to show that child 1 - 6 have verification of receipt of a copy of the Licensing report dated 05/21/19 where Licensee was issued a Type A citation. 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: 12/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2019
LIC809 (FAS) - (06/04)
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