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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415325
Report Date: 03/29/2024
Date Signed: 03/29/2024 02:49:47 PM


Document Has Been Signed on 03/29/2024 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:HUYNH, TINAFACILITY NUMBER:
434415325
ADMINISTRATOR:HUYNH, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 687-8099
CITY:SAN JOSESTATE: CAZIP CODE:
95127
CAPACITY:14CENSUS: 11DATE:
03/29/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Tina HuynhTIME COMPLETED:
01:45 PM
NARRATIVE
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On 3/29/24 Licensing Program Analyst (LPA) Sheena Chin met with Licensee, Tina Huynh, for an unannounced annual inspection. LPA explained the nature of today’s inspection. Present during today’s inspection were the licensee, 2 helpers and 11 children in the facility. Days and hours of operation are Monday to Friday, 8:30am to 5:00pm. The adults that reside in the home are the licensee, her husband, and her mom. The licensee stated that her mom moved in after the licensure and had background clearance. LPA advised the licensee that any adults resided in the house also needed TB test result. The licensee claimed the ownership of the home.

Observation
LPA observed that required postings were posted but were blocked by other posters and a calendar. LPA advised the licensee to expose the required documents completely. The licensee removed the calendar and rearranged the posters accordingly. LPA, along with the licensee, toured the inside and outside of the home. The facility has a full charged fire extinguisher, 3A40BC. Carbon monoxide and smoke detectors are working properly. The off-limit areas inside in the home are all 3 bedrooms, kitchen, and garage.

All disinfectant, cleaning supplies, and other items that could pose a risk to children were observed to be inaccessible. LPA observed that there are toys for children. LPA conducted CARE Tools for this annual inspection, which include Physical Plant, Care and Supervision, Facility Administration, Records, Staffing Ratio and Capacity, Personnel Rights for compliance with all licensing statutes, regulations, and interim licensing Standards, and results were documented on the tool.

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SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena ChinTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HUYNH, TINA
FACILITY NUMBER: 434415325
VISIT DATE: 03/29/2024
NARRATIVE
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Records review
The Licensee has current CPR and First Aid certifications expiring on 2/5/25. The Licensee has the child abuse training certificate, expiring on 3/15/26. LPA reviewed the fire and disaster drills log which is to be done at least once every six months. The last drills were conducted on 3/15/24.

LPA reviewed all children files. Immunization records are maintained and updated in PM171 A. LPA advised the licensee to maintain and update the immunization records on PM286. LPA gave the licensee a copy of PM286. LPA observed Notification of Parents’ Rights is in each child’s file. Sleeping charts were not maintained in C6 files. The licensee stated that she did not know that she needed to document and maintain the sleeping checks. The two helpers did not have immunization clearances and mandated reporter training certificates. S2 was hired in late February. LPA advised the licensee to have S2 complete mandated reporter training within the first 90 days that she was employed at the facility.

During today’s inspection, all adults present or residing in the home have criminal record clearances required by the Department. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

Discussion

Supervision of children was discussed with Licensee, who understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options. Licensee states that she does not transport children via vehicle but she understands that children cannot be left in parked vehicles unattended at any time.



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SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena ChinTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HUYNH, TINA
FACILITY NUMBER: 434415325
VISIT DATE: 03/29/2024
NARRATIVE
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Discussion
LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

The Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Deficiency
Regulatory violations were observed during the inspection. Therefore, citations were issued.

Further questions
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

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SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena ChinTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HUYNH, TINA
FACILITY NUMBER: 434415325
VISIT DATE: 03/29/2024
NARRATIVE
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Exit
During the exit interview, the Licensee, Huynh Tina, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.
Exit interview was conducted, where this report, the citation, plan of correction, and appeal rights were reviewed and discussed with Licensee, Huynh Tina.
Notice of site visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Gladys KuizonTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena ChinTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 03/29/2024 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: HUYNH, TINA
FACILITY NUMBER: 434415325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Sleeping charts were not maintained in C6 files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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The licensee will send LPA a copy of the sleeping chart for 5 days.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Helper, S1, did not have current mandated reporter training certificate, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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The licensee will send LPA the copy of the mandated reporter training certificate for S1.
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: Gladys KuizonTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena ChinTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 03/29/2024 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: HUYNH, TINA
FACILITY NUMBER: 434415325

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. The two helpers did not have immunization clearances, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2024
Plan of Correction
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The licensee will send LPA the copies of the immunization records for two helpers.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Gladys KuizonTELEPHONE: (408) 324-2151
LICENSING EVALUATOR NAME: Sheena ChinTELEPHONE: (408) 324-2148
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6