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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416393
Report Date: 08/20/2021
Date Signed: 08/23/2021 10:42:21 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, ANHFACILITY NUMBER:
434416393
ADMINISTRATOR:NGUYEN, ANHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 338-8346
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 13DATE:
08/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:22 AM
MET WITH:Anh NguyenTIME COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Samantha Yip and Cortney Nelson conducted an unannounced Required- 1 Year inspection. LPAs met with Licensee Anh Nguyen and explained the reason for the inspection. Present during today's inspection were Licensee, two assistants, and 12 children, whom one was infant age and two were school-age. One more child arrived shortly after. All adults present have cleared fingerprint clearance.

There is board to post required postings, such as license. LPA reminded Licensee that the notification of parent's right and emergency disaster plan need to be posted. The hours of operation are Monday through Friday 7AM to 6PM. There is working phone in the home.
LPAs toured the inside and outside of the home with Licensee. The off-limit areas of the home are the entire upstairs, living room, dining room, kitchen, closet downstairs, laundry room, garage, and the left side of the backyard. There is a fireplace in the home, which is barricaded. There is also stairs in the home. Licensee has a gate in the hallway prior to stairs. There is sufficient amount of toys for children in care. Equipment and furniture were observed to be in good condition. LPAs observed that there was a bottle of hand sanitizer and a box of Clorax toilet bowl cleaner under the sink in the bathroom. Licensee moved the bottle of hand sanitizer and the box of Clorax toilet bowl cleaner to the laundry room. LPA reminded Licensee that anything that states to keep out of reach of children needs to be stored inaccessible. There is fully charged fire charged, functioning smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 02/2020. LPA reminded Licensee that fire/disaster drill need to be conducted every 6 months and

------------------CONTINUES ON 809 DATED 08/20/2021 PAGE 2--------------------------------
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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 7
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: 08/20/2021
NARRATIVE
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------------------CONTINUATION OF 809 DATED 08/20/2021 PAGE 1----------------------------

documented. Licensee stated that she will conduct fire/disaster drill and send proof to Licensing.

The backyard is used and is fenced. LPAs observed that there is a pond in the backyard, which is filled. There a mesh around the pond, which is attached to a fencing on the top. There is gate on the fencing, which swings inward and the mesh starting to give way and ripe, which is leading to a gap between the fence and mesh. Licensee understands that whenever she has a body of water, such as pond, that it needs to have the required fencing. Licensee stated that is going to have someone install a fence around the pond. There were no other bodies of water observed during today's inspection. LPAs observed that one of the play structure has a crack across the top. Licensee stated that she is going to throw away the play structure.

Licensee stated that she does not transport children, but understands that children cannot be left alone and unattended in parked vehicles. Licensee also stated that she does not provide Incidental Medical Services (IMS).

A copy of the facility roster was obtained. 12 children's files were reviewed during today's inspection. The records reviewed include but not limited to Identification of Emergency Contact and consent for medical treatment. LPAs observed that children were missing the second page of the Identification of Emergency Contact. LPAs observed that children have the LIC 627A instead of the LIC 627 in file. Licensee stated that she will have parents of children sign LIC 627 and send proof to Licensing.



-----------------CONTINUES ON 809 DATED 08/20/2021 PAGE 3-------------------------------
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/27/2021
Section Cited

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Operation of Family Child Care Home. Each family child care home shall conduct fire drills and disaster drills at least once every six months.
This requirement was not met as evident by:
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Based on record reviews, the last fire/disaster drill was conducted on 02/2020. This poses a potential risk to the health and safety to the children in care.
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Type B
08/27/2021
Section Cited

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Operation of Family Child Care Home. Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.
This requirement was not as evident by:
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Based on observation, LPAs observed that there Clorax toilet bowl cleaners under the sink in the bathroom. The bag of cleaners was in an unopen bag. This poses a potential risk to the health and safety to the children in care.
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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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 7 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/20/2021
Section Cited

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Personnel Requirements. A licensee of a large family day care home shall ensure that at least one person who has a current certificate in pediatric first aid and pediatric cardiopulmonary resuscitation shall be available at all times....
This requirement is not met as evident by:
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Based on record reviews, Licensee's CPR/1st Aid expired on 02/2021. No other assistants have a valid CPR/1st Aid. This poses a potential risk to the health and safety to the children in care.
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Type B
08/27/2021
Section Cited

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Personnel Records. Personnel records shall be maintained on each employee and shall contain the following information...Notice of Employee Rights...signed statement regarding their criminal record history...
This requirement was not met as evident by:
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Based on record reviews, both Assistants did not have any of the required forms. This poses a potential risk to the health and safety to the children in care.
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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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2021
Section Cited

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AB 1207 Mandated Child Abuse Reporting Training. On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility complete the mandated reporter training... 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 was not met as evident by:
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Based on record reviews, Licensee last completed the Mandated Reporter training on 11/09/2018 and A-2 have not completed the Mandated Reporter training. This poses a potential risk to the health and safety to the children in care.
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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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 6 of 7
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2021
Section Cited

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Operation of Family Child Care Home. All licensees shall ensure the inaccessibility of ...fish ponds...through a pool cover or by surrounding the pool with a fence.
This requirement was not met as evident by:
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Based on observation, LPAs observed that there was a pond in the backyard, which has a mesh surrounding it that was attached to a fence. The fence had a gate, which swing inward and the mesh below the gate was starting to give way and ripe. This poses an immediate risk to the health and safety to the children in care.
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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: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 5 of 7
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: 08/20/2021
NARRATIVE
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------------------CONTINUATION OF 809 DATED 08/20/2021 PAGE 2--------------------------

LPA also reviewed Licensee and Assistant's file. A-1 and A-2 have immunization records for measles and pertussis, but does not have any of other required forms. A-1 and A-2 does not have a TB test results within the year. Licensee stated that she is going to have A-1 and A-2 will obtain TB test results. Licensee does not have a valid CPR/1st Aid. Her CPR/1st Aid expired on 02/2021. She stated that she will complete the CPR/1st and send proof to Licensing. Licensee last completed her Mandated Reporter training on 11/09/2018. Licensee understands that Mandated Reporter training needs to be renewed every two years. Licensee stated that A-1 started working with her a month ago. Licensee understands that she has 90 days for any new assistants to complete the Mandated Reporter training. Licensee stated that A-2 has not completed the Mandated Reporter training. Licensee stated that her assistants and herself will complete the Mandated Reporter training and send proof to Licensing.

The adults living in the home are Licensee, her spouse, and her adult step-daughter. All adults have cleared criminal record and child abuse index clearance. Licensee and her spouse have TB test results.

As a result of this inspection, one Type A citation, Type B citations, and one Technical Violation have been cited. A civil penalty of $500 was assessed during today's inspection for immediate $500. An exit interview was conducted where this report, citations, plan of correction, civil penalty, and appeal rights were discussed and provided to Licensee Anh Nguyen.

LPA also discussed about AB 633 requirement to provided a copy of 809 report dated 08/20/2021 and obtain a signed copy LIC 9224 for each child in care within one business day. LPA also discussed with Licensee Anh that a copy of this report and a signed copy of LIC 9224 is required for any newly enrolled children within the 12 month period. LPA will email a copy of LIC 9224 and fact sheet to Licensee Anh.

A Notice of Site Visit has been issued and must be posted for 30 consecutive days; along with a copy of the report.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC809 (FAS) - (06/04)
Page: 4 of 7