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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415162
Report Date: 08/14/2019
Date Signed: 08/14/2019 11:43:38 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:PHAN, NGAN & NGUYEN, NGUYENFACILITY NUMBER:
434415162
ADMINISTRATOR:NGAN & NGUYENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 226-0398
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY:14CENSUS: DATE:
08/14/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Ngan Phan & Nguyen NguyenTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Mel Matos and Dung Mac met with Ngan Phan & Nguyen Nguyen, Licensees, for unannounced annual/random inspection. LPA also observed fourteen day care children (2 infants, 9 preschool, & Licensees 3 school age children) in the home during today's inspection. Days and hours of operation are Monday - Friday from 8:00 AM to 6:00 PM. The Licensees and two adult renters are the adults residing in the home. The Licensees CPR & First Aid certifications expired on September 24, 2018 and have not been renewed as of today's inspection.

LPAs reviewed a current Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on July 2, 2019. The Licensees did not have a current Child Care Children's Roster available during today's inspection. LPAs reviewed thirteen children's files and observed that all thirteen files are incomplete & missing required forms. LPAs observed that the Licensee has record of MMR & Tdap vaccinations on file. The Licensees state that they will submit copies of current flu vaccines to the Department. The Licensees have completed the Mandated Reporter training for child care workers and copies of the certificates of completion are on file.

LPAs toured the indoor and outdoor areas of the home during today's inspection. The Licensees have a working telephone in the home. LPAs observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPAs did not observe any wall heaters inside the home. LPAs observed a barricaded gas fireplace unit in the living room area of the home. There are no stairs inside the home. Off limit areas inside the home: four bedrooms, two bathrooms, storage closet area, and home office. Off limit areas outside the home: left, right, and rear back sections of the backyard.

LPAs observed a fully charged 2A10BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water during today's inspection. The Licensees state that they do not have any weapons in the home. The Licensees have four dogs (1 Labrador, 2 Chihuahua, and 1 Terrier) that are kept in the off limits areas of the backyard. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. The Licensees state that they do not administer any medication to the day care children.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 08/14/2019):
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
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 4
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: PHAN, NGAN & NGUYEN, NGUYEN
FACILITY NUMBER: 434415162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2019
Section Cited
CCR
102416(c)
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Personnel Requirements: The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
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The Licensees agreed to renew their CPR & First Aid certifications and submit updated copies of the First Aid & CPR certifications to LPA Mac by Monday September 16, 2019.
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This requirement is not met as evidenced by: The Licensees CPR & First Aid certifications expired on September 24, 2018. This presents a potential risk to the health & 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: PHAN, NGAN & NGUYEN, NGUYEN
FACILITY NUMBER: 434415162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2019
Section Cited
CCR
102421
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Child's Records: The Licensees shall maintain current child(ren) records at all times. This requirement is not met as evidenced by: LPAs reviewed thirteen children's files and observed that all 13 files are incomplete & missing required forms.
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The Licensees agreed to update all thirteen children's files by Friday August 23, 2019. LPAs provided the Licensees with an updated Children's file packet. LPAs advised the Licensees that a follow up inspection
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This presents a potential risk to the health and safety of children in care.
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will be conducted to verify completion of the Plan of Correction
Type B
08/23/2019
Section Cited
CCR
102417(g)(8)
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Operation of a Family Child Care Home: Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841. This requirement is not met as evidenced by:
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The Licensees agreed to submit a current Child Care Facility Roster to LPA Mac by Friday August 23, 2019
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The Licensees did not have a current Child Care Children's Roster available during today's inspection.
This presents 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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: PHAN, NGAN & NGUYEN, NGUYEN
FACILITY NUMBER: 434415162
VISIT DATE: 08/14/2019
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 08/14/2019):

A review of staff records on August 8, 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. LPAs also reminded the Licensees 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 they understand that they must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensees understand their capacity options and they understand that they cannot have more than 14 children in the home at any time when at least two qualified adults are present in the home. The Licensees state that they don't employ any assistants in the day care. LPAs reminded the Licensees that their three children (ages 9 & 7 years) count against the licensed capacity whenever they are present in the home. The Licensees state that they not transport any day care children.

LPAs reminded the Licensees that effective January 1, 2019 Assembly Bill 2370 requires that all licensed homes to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. LPAs provided a copy of the “Lead Poisoning Facts Information Flyer” to the Licensees. Safe sleep information & handout was also discussed with the Licensees.

The following deficiencies are cited on the attached page (809-D). Appeal rights were provided to the Licensees prior to the conclusion of today's inspection.

LPAs conducted an exit interview with the Licensees prior to the conclusion of today's inspection and the Licensees agreed to submit the following items to LPA Mac by Friday August 23, 2019: 1) Updated Application for a Family Child Care Home (LIC 279), Current Children in Your Home (LIC 279B), and Updated Emergency Disaster Plan (LIC 610A).

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: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4