434416179-4-21-2021-07-CC-JCRZ-C2AW2Z-20210421165510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416179
Report Date: 04/21/2021
Date Signed: 04/21/2021 04:56:01 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:	THAN, KHANH		FACILITY NUMBER:	434416179
ADMINISTRATOR:	KHANH THAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 597-7816
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95111
CAPACITY:	14	CENSUS: 14	DATE:	04/21/2021
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Khanh Than		TIME COMPLETED:	05:00 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	Licensing Program Analysts (LPAs) Janette Cruz and Mel Matos conducted an announced case management tele-inspection (via FaceTime) and spoke with Thanh Khan, Licensee. The Licensee has an adult assistant with total of 14 children (one infant, ten pre-school and three school-age) in care, present in the home today. On 4/16/21, LPA Janette Cruz became aware that the Licensee has an adult renter, Talita Miranda, residing in the home since March 2021 (exact date cannot be recalled by Licensee). Talita Miranda did not obtain her criminal record and child abuse index clearances until April 18, 2021. LPAs verified the Department Licensing Information System (LIS) on April 19, 2021 and confirmed that Talita Miranda obtained the Department of Justice (DOJ), Federal Bureau of Investigation (FBI) and the Child Abuse Child Index (CACI) clearances on April 18, 2021. A “Type A” deficiency is being cited today based on interviews conducted and record reviews in accordance with the California Code of Regulations, Title 22 (see LIC 809-D). Civil penalties was assessed during today's tele-visit. LPA discussed the requirements of AB633 to licensee and provided her the AB633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC9224) and licensee understands the requirements. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. Report continued on the following page (809-C):

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021

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: THAN, KHANH	FACILITY NUMBER: 434416179
	VISIT DATE: 04/21/2021

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
26
27
28
29
30
31
32

A Notice of Site Visit will also be forwarded to Thanh Khan, Licensee, via email and will be required to be posted near the entrance to the day care along with today’s report for 30 days.

An exit interview was conducted and a Plan of Correction was reviewed and developed with the Licensee. A copy of this report and appeal rights was discussed with the Licensee. LPA, Janette Cruz to forward a copy of today’s report to Than Khanh, Licensee, via email (kellythan1991@yahoo.com). LPAs requested that Licensee respond to the “read receipt” confirmation/send confirmation of receipt email to LPA Janette Cruz within 24 hours confirming receipt of today’s report.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021

LIC809 (FAS) - (06/04)

Page: 2 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: THAN, KHANH	FACILITY NUMBER: 434416179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/21/2021 Section Cited	1 2 3 4 5 6 7	102370 (d)(1) Criminal Record Clearance - All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility obtain a California clearance or a criminal record exemption as required by the Department. This requirement was not met as evidenced by:
	8 9 10 11 12 13 14	Based on record reviews and interviews, adult renter, Talita Miranda, did not obtain her criminal record and child abuse index clearances until 4/18/21. This poses an immediate threat to health and safety of children in care.	8 9 10 11 12 13 14	Civil penalty of $500 assessed today (see LIC 421BG). The Licensee must provide copies of this report to parents/guardians of children in care at this facility and to parents/guardians of children newly enrolled at this facility during the next 12 months per the AB633 requirements.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2021

LIC809 (FAS) - (06/04)

Page: 3 of 3