434416393-8-21-2019-07-CC-SYIP-BF9LBQ-20190821083707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416393
Report Date: 08/20/2019
Date Signed: 08/21/2019 08:37:14 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:	NGUYEN, ANH		FACILITY NUMBER:	434416393
ADMINISTRATOR:	NGUYEN, ANH		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 338-8346
CITY:	GILROY	STATE: CA	ZIP CODE:	95020
CAPACITY:	14	CENSUS: 0	DATE:	08/20/2019
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	Anh Nguyen		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) Samantha Yip conducted an announced pre-licensing inspection. LPA met with Applicant Anh Nguyen and explained the reason for the inspection. The purpose of this inspection is Applicant is applying for a Large Family Child Care Home. Applicant does have over one year of experience as a licensee of a small family child care home and working as a teacher in a child care home. A fire clearance for a Large Family Child Care Home was granted on 08/16/2019. The adults living in the home are Applicant and her spouse. Adults living in the home have fingerprint clearance and TB test results. Applicant stated that her adult step-daughter and mother does sometimes come to visit. LPA discussed with Applicant about ensuring that anyone staying over 30 days is fingerprint cleared and has TB test results. Applicant does have one minor child that lives in the home. LPA observed there is a board to post required posting, such as license, emergency disaster plan, notification of parent's rights, and earthquake preparedness checklist. There is working phone in the home. The hours of operation are Monday through Friday 7AM to 6PM. LPA toured the inside and outside of the home with Applicant. The off-limit areas of the home are entire upstairs, living room, dining room, kitchen, laundry room, garage, the pond in the backyard, and shed area on the left side of the backyard. There are stairs in the home, which were not barricaded. Applicant stated that she will either be placing a gate on the stairs or on the hallways before the laundry room. There is a fireplace in the home, which has a cover to prevent access to the daycare children. All disinfectants and cleaning supplies inside the home were stored inaccessible to the children in care. LPA observed there is sufficient amount of toys for children in care. There were no baby walkers or -------------------continues on 809 dated 08/20/2019 page 2-------------------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2019

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 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: NGUYEN, ANH	FACILITY NUMBER: 434416393
	VISIT DATE: 08/20/2019

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

-------------------continuation of 809 dated 08/20/2019 page 1----------------------------------

bouncers observed. Applicant understands baby walkers and bouncers are not permitted in the home. Applicant also understands that smoking is not permitted. LPA also observed a fully charged fire extinguisher, functioning carbon monoxide detector, and smoke detector. LPA discussed with Applicant about fire/disaster drills need to be conducted every 6 months and documented. There is pond in the backyard which has a gate surrounding it and has a child's lock. The fence is 2ft 6 inches. LPA discussed with Applicant about the requirements for any bodies of water. Applicant stated that she will drain the water in the pond. LPA observed that the fenced leading to the shed area is not locked and there are ant repellent and other chemicals in a storage container in the backyard. Applicant stated that she will be moving the storage container to the shed area and will be buying a lock for the fence leading to the shed area.

Applicant's CPR/1st Aid expires on 02/2021. Applicant has completed the Mandated Reporter Training on 11/09/2018. LPA reminded Applicant that Mandated Reporter Training needs to be renewed every 2 years. Applicant's immunization records for pertussis and measles and her Preventive Health and Safety certificate are on file.

LPA provided Applicant with a Family Child Care Home packet with updated Licensing forms and reviewed with the Applicant. Department website: www. ccld.ca.gov provided to the Applicant. Applicant does not have daycare insurance at this time and will use Affidavit Regarding Liability Insurance to inform parents that she does not have a daycare insurance. Applicant does not plan on transporting children, but is aware that children will not be left unattended in a parked vehicle. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, requirements for assistant/substitute, and immunization requirements for staff including the new regulation regarding Pertussis, Measles, and Influenza were discussed with Applicant. LPA also discussed with Applicant about having age-appropriate equipment, such as having individual cribs/play yards for infants. LPA also discussed safe sleep information with Applicant. LPA discussed healthy beverages in child care and violation that would result in an immediate civil penalty of $500 with Applicant.

----------continues on 809 dated 08/20/2019 page 3-------------------------------------

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2019

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: NGUYEN, ANH	FACILITY NUMBER: 434416393
	VISIT DATE: 08/20/2019

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

-----------continuation of 809 dated 08/20/2019 page 3----------------------------------

LPA informed Applicant 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.

Applicant does not plan on providing Incidental Medical Service at this time. Incidental Medical Services (IMS) policy was discussed. For IMS information, see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Home Section 102417. When any IMS is provided, a Plan of Operation that includes 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: http://www.ada.gov/childqanda.htm.

LPA conducted an exit interview with Applicant. LPA advised Applicant upon approval of Licensing Management, a license for a Large Family Child Care Home will be granted and issued to Applicant upon completion of the following items:

barricading stairs
putting a lock on the gate leading to the shed area
placing any chemicals, such as ant repellent, in an inaccessible area
draining the pond

SUPERVISOR'S NAME: Anthony Studebaker	TELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha Yip	TELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2019

LIC809 (FAS) - (06/04)

Page: 3 of 3