435700317-5-24-2021-52-CC-MESA-C3BQ5G-20210524115154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435700317
Report Date: 05/24/2021
Date Signed: 05/24/2021 11:52:02 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME:	PONGCHANA, NOPPAKET		FACILITY NUMBER:	435700317
ADMINISTRATOR:	NOPPAKET PONGCHANA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 703-7818
CITY:	MILPITAS	STATE: CA	ZIP CODE:	95035
CAPACITY:	14	CENSUS: 7	DATE:	05/24/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Noppaket Pongchana		TIME COMPLETED:	12:00 PM

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On 05/24/2021 at 10:25 AM, Licensing Program Analyst (LPA) Manel Estoesta conducted an unannounced Case Management inspection to provide a Regular Family Child Care Home Large License from a Provisional License. Provisional License was provided on 05/11/2020 and will expire on 06/11/2021. Fire Safety Inspection Request STD 850 was approved by Milpitas Fire Department on 05/10/2021.

LPA met with the Licensee NOPPAKET PONGCHANA. Present for this visit were fingerprinted and criminal record cleared RATTIMA NITISAROJ, two (2) assistant Stacie Phan and Tuoi Nguyen, four infants and 3 preschool chidlren. The applicant's address is 583 ODDYSEY LANE, MILPITAS, CA 95035. The home was toured to conduct a Health and Safety Inspection. Hours of operation will be from Monday to Friday 7 AM to 6 PM.

The home is single-family three (3) story home. The applicant owns the house. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are the bedroom (for napping), family room, reading room, bathroom and the backyard. The BACKYARD play area is completely fenced. The designated isolation area for a child who becomes ill while in care is the reading room. The OFF-LIMIT AREAS are the entire second floor, the entire third floor and the garage which will be inaccessible to children in care by closed and or locked doors and or a fence with visual supervision.

There are ample age appropriate toys that appear to be safe and in good condition. 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. The home has a fully charged fire extinguisher 2A10BC, working smoke detector, carbon monoxide and a telephone (mobile phone). Per applicant, there are no firearms on the premises. Fire Disaster Drill was conducted on 01/22/2021 and 05/10/2021.

Children's Files were reviewed.

See 809-C for continuance.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel Estoesta	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PONGCHANA, NOPPAKET	FACILITY NUMBER: 435700317
	VISIT DATE: 05/24/2021

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The applicant completed the Health and Safety, Pediatric CPR and First Aid training (expires on 05/23/2023). The packet of forms pertaining to the children’s files, facility files, the New Safe Sleep Brochure, Lead Poisoning Facts Flyer and California Child Safety Seat Law to the licensee, reviewed, discussed by LPA Estoesta. The applicant has proof of immunization requirements and has completed the AB 1207 – California Child Care Providers: Mandated Reporter Training (taken on 02/24/2020).

The Department’s website to access resources for Providers, Title 22 Regulations, online option to pay Annual License fee, all forms can be downloaded, Child Care Resource & Referral Network (R&Rs) and more information at https://cdss.ca.gov/inforesources/child-care-licensing. This website link https://ccld.childcarevideos.org/ includes videos that explain licensing topics relevant to families and licensed child care providers.

Effective August 1, 2003 California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624B). Incidents must be reported within 24 hours by phone, fax, or electronic mail.

Individual Medical Services (IMS) policy was discussed. 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/childqanda.htm.

Any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility.

See 809-C for continuance

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel Estoesta	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PONGCHANA, NOPPAKET	FACILITY NUMBER: 435700317
	VISIT DATE: 05/24/2021

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All assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. To file a complaint regarding a state licensed community care facility or child care facility, call Community Care Licensing Division Complaint Hotline 1-844-538-8766 or email letusno@dss.ca.gov.For licensing updates, advised applicant to email childcareadvocatesprogram@dss.ca.gov and request to be added to the email list.

The facility is recommended and approved for a Regular Family Child Care Home License effective today 05/24/2021

No deficiency cited during today’s visit.

An exit interview was conducted with the licensee. The licensee was provided a copy of the appeal rights and the signature on this form acknowledges receipt of these rights. A Notice of Site visit was posted at the time of inspection and must remain posted for 30 days.

End of report.

SUPERVISOR'S NAME: Jason Jang	TELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Manel Estoesta	TELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021

LIC809 (FAS) - (06/04)

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