434416179-9-15-2021-07-CC-JCRZ-C6VNM7-20210915103441

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416179
Report Date: 09/15/2021
Date Signed: 09/15/2021 10:34:50 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:	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: 12	DATE:	09/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:22 AM
MET WITH:	Khanh Than		TIME COMPLETED:	11:00 AM

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 Analyst (LPA) Janette Cruz met with Khanh Than, Licensee, for an unannounced Required – 1 year annual inspection. LPA explained the purpose of the visit and was granted access to the home by the Licensee. LPA also observed 12 children (2 infants and 10 preschool), Licensee's mother and Licensee's adult assistant in the home during today's inspection. The Licensee was operating within her capacity and ratio requirements during today's inspection. LPA observed the required postings, including the facility license, located in the living room of the home. The home has a working telephone (408) 597-7816. Days and hours of operation are Monday - Friday from 7:00AM to 6:00PM. The Licensee, her spouse, Vu Le and Licensee's renters, Graciela Ariasmunoz, Claudia Diazgomez, Talita Miranda and Esther McKoon are the adults residing in the home. The Licensee's CPR and First Aid on file expires on 04/2023. LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 07/2021. The Licensee and adult assistants have the required vaccinations (MMR, Tdap, & flu opt-out). The Licensee’s Mandated Reporter Training for Child Care Workers on file expired on 08/10/21. LPA reviewed 12 children's files and observed current and updated Identification and Emergency Information (LIC 700) and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file. The Licensee states that a child will be isolated in the living room if needed to because of illness or communicable disease. LPA discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee. REPORT CONTINUED ON FOLLOWING PAGE #2

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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: THAN, KHANH	FACILITY NUMBER: 434416179
	VISIT DATE: 09/15/2021

NARRATIVE

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LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed the home is a two-story house with barricaded stairs. The home is clean, orderly with heating and ventilation for safety and comfort of children. LPA observed a built-in children's cabinet making the fireplace unit inaccessible to children. Off limit areas inside the home: ADU converted garage, barricaded kitchen, front yard and entire second floor. The whole backyard is fully fenced and approved for use of children. LPA observed no bodies of water.

LPA observed a fully charged 3A40BC fire extinguisher and working smoke/carbon monoxide detectors. The Licensee states that there are no weapons in the home. LPA observed Licensee has two small dogs the home that are kept away from children. All detergents, cleaning compounds, medications, and other similar items are stored in high cabinets inaccessible to children. LPA observed any poisons are locked in the shed at the backyard inaccessible to the day care children. Licensee has current child care liability insurance coverage on file.

A review of staff records on 09/15/21 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license

REPORT CONTINUED ON FOLLOWING PAGE #3 :

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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: THAN, KHANH	FACILITY NUMBER: 434416179
	VISIT DATE: 09/15/2021

NARRATIVE

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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 she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time without a fully qualified adult present. The Licensee states that she does not transport day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA conducted an exit interview and advised Licensee that a deficiency is issued during today's inspection. See 809-D.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette Cruz	TELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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: THAN, KHANH	FACILITY NUMBER: 434416179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/15/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/15/2021 Section Cited	1 2 3 4 5 6 7	1596.8662 (4)(b)(1)On or before 03/30/18, a person who on 01/01/18 is a licensed child day care provider shall complete the mandated reporter training......every two years following the date on which she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on observation, interviews and record reviews, Licensee mandated reporter training certificate expired on 8/2021 which poses a potential threat on health and safety of children.	8 9 10 11 12 13 14
	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: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC809 (FAS) - (06/04)

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