434416179-10-11-2024-07-CC-AYAG-D9XTF9-20241011144110

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416179
Report Date: 10/11/2024
Date Signed: 10/11/2024 02:42:06 PM

Document Has Been Signed on 10/11/2024 02:42 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:	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: 10	DATE:	10/11/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	11:23 AM
MET WITH:	Khanh Than		TIME COMPLETED:	02:55 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	At 11:23 AM, Licensing Program Analysts (LPAs) Andy Yang and Mandeep Kaur met with Licensee, Khanh Than to conduct an unannounced annual 3-YEAR REQUIRED inspection. Present for this inspection was Licensee, 2 Assistants, 11 Children (3 Infants and 8 Preschool age), and 3 Adults (Renters). The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday to Friday 7:00 AM to 6:00 PM. The home is Single Family Home with two stories. The home consists of (1st floor) Living Room, Bathroom, Kitchen, ADU, (2nd floor) Master Bedroom, Bathroom, Room 1, Room 2, Room 3, Laundry Room, Backyard, Side yard . The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are Living room, Bathroom, Backyard, and Side yard. The OFF LIMIT AREAS are entire 2nd floor and ADU. which will be inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA is front left side of the living room (sleeping area). The outdoor play area is free from defects or dangerous conditions and is fenced. There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are ample age-appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs, or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children, and it was observed that there are no toxins or hazardous items accessible today. Licensee states that any poisons are stored in locked cabinet in the kitchen which is OFF LIMITS. LPAs reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. The home has two fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The Licensee CPR and First Aid certificate is current and expires 03/2026. Licensee completed the Mandated Reporter Training for Child Care Providers on 2/13/2024 (Expires 2/13/2026) and a copy of the certification is on file. Licensee was reminded of Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. Per Licensee, there are no firearms in the home. The Licensee conducts and documents fire and disaster drills every six months. Personnel records are available for review and contain all required forms. Child’s records are available for review and contain all required forms. All REQUIRED forms are posted and visible for public review. *Page 2*

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Andy Yang	TELEPHONE: (408) 497-3126
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: THAN, KHANH	FACILITY NUMBER: 434416179
	VISIT DATE: 10/11/2024

NARRATIVE

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All cribs or play yards meet the safety standards. The cribs or play yards do not hinder entrance or exit to and from the space where infants are sleeping. The mattresses in the crib or play yards are firm and covered with a fitted sheet that is appropriate, fits tightly, and overlaps the underside of the mattresses. Each infant’s bedding is used for them only and cleaned weekly or before use by another infant. There are no loose articles and objects, bumper guards or objects hanging above or attached to the side of the cribs or play yards. Each infant under 12 months of age has an Individual Infant Sleeping Plan maintained in the file signed and dated by the infant’s authorized representative.

Forms of discipline to be used by Licensee are redirecting and talking with the child. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature.

Also, discussed with the Licensee was isolation of sick children, supervision of children, staffing ratio and capacity, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute.

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.

Licensee notified the LPAs that there are 3 Adults living in the home. LPA reminded that criminal record clearance and TB test must be completed for any adults living in the home.

***Continue Page 3***

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Andy Yang	TELEPHONE: (408) 497-3126
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: THAN, KHANH	FACILITY NUMBER: 434416179
	VISIT DATE: 10/11/2024

NARRATIVE

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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-andresources/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/.

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.

During the exit interview, the LICENSEE, Khanh Than, confirmed that there are no Registered Sex Offenders living in the facility and LPA Yang completed the RSO profile in FAS. Megan's Law was checked on 10/03/2024.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

During today’s inspection, two “Type B” deficiencies are issued on attached 809-D. Appeal rights provided.

Licensee will provide an updated LIC 279, and updated Facility Roster LIC9040.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Licensee, Khanh Than

SUPERVISOR'S NAME: Belinda Devall	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Andy Yang	TELEPHONE: (408) 497-3126
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 10/11/2024 02:42 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: THAN, KHANH	FACILITY NUMBER: 434416179
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2024

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
1 2 3 4	Based on records review and interview of Staff (S1) the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2024
	Plan of Correction
1 2 3 4	By POC date: 10/25/2024, the Licensee will submit proof of immunization of measles, pertussis, infuenza, and TB Clearance for Staff (S1).

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above for infants (C2 & C3) in which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	By POC date: 10/18/2024, the licensee will submit proof of the Individual Infant Sleeping Plan for all Infants (C2 and C3).

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: Belinda Devall	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Andy Yang	TELEPHONE: (408) 497-3126
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024

LIC809 (FAS) - (06/04)

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