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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416393
Report Date: 10/19/2021
Date Signed: 10/19/2021 02:43:11 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:NGUYEN, ANHFACILITY NUMBER:
434416393
ADMINISTRATOR:NGUYEN, ANHFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 338-8346
CITY:GILROYSTATE: CAZIP CODE:
95020
CAPACITY:14CENSUS: 11DATE:
10/19/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Nguyen, AnhTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Plan of Correction (POC) inspection. LPA met with Licensee Anh Nguyen and explained the reason for the inspection. The purpose of this inspection is Licensee was cited on 08/20/2021 for not having pond fenced, children's file, and staff files. Present during today's inspection were Licensee, two assistants, and 11 children, whom 1 was infant age.

During today's inspection, LPA inspected the wooden fence installed around the pond. The fence around the pond meets the requirements. LPA observed that the height of the fence was at least 5 feet high and the gaps between the panels are no more than 4 inches wide. There is a latch on the gate, which has a zip-tie around it so it locked.

LPA reviewed 15 children's files. All children had the second page of the LIC 700 filled out and signed; along with the LIC 627 and LIC 9224. LPA observed that C-1 did not have the LIC 9227 in their file. Licensee stated that she will have C-1's parent sign form and send proof to Licensing.

LPA also reviewed 2 staff files. LPA observed that S-1 did not have proof of pertussis on file and TB test was from 2018. Licensee stated that she started working on 09/2021. LPA discussed with Licensee that TB test results need to current and cannot be more than a year old. Licensee stated that she will send proof to Licensing by 11/19/2021. LPA reminded Licensee to ensure that all assistants have all forms filled out and in file, such as LIC 9108.

LPA also discussed with Licensee about not having anything hanging over the play yard.

As a result of this inspection, no deficiencies were cited. An exit interview was conducted where this report was discussed and provided to Licensee Anh Nguyen. A Notice of Site Visit was given and must remain posted for 30 days.
SUPERVISOR'S NAME: Anthony StudebakerTELEPHONE: (408) 324-2148
LICENSING EVALUATOR NAME: Samantha YipTELEPHONE: (408) 529-8128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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