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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409509
Report Date: 08/13/2024
Date Signed: 08/13/2024 11:33:36 AM

Document Has Been Signed on 08/13/2024 11:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:NGUYEN, NHAFACILITY NUMBER:
073409509
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
08/13/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:NHA NGUYENTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 8/13/2024 at 8:30am Licensing Program Analyst (LPA) Tasha Alexander met with Licensee Nha Nguyen (Nya) for an Annual/Random and Increase of Capacity Inspection. Present during the inspection was the Licensee, her visiting aunt, three (3) preschool age child and three (3) infants. Licensee lives in the home with her husband, Lucas Livingstone, and their two minor children, ages 12 and 13 years old. Licensee’s home was toured for a health and safety inspection. The facility operates from 8:00am – 6:20pm, Monday - Saturday.

ON LIMITS AREA: Living room, dining room, downstairs bathroom near the family room, kitchen and the patio area of the backyard.

OFF LIMITS AREA: the 3rd level of the home which includes all 4 bedrooms and 2 bathrooms, the downstairs laundry room, garage, the swimming pool area and the fenced off right side of the backyard which stores the garbage cans.

Licensee was reminded that due to the backyard having a body of water, adult physical presence/supervision is needed while children are in the backyard playing.


ISOLATION AREA: The on-limits living room on the couch away from the other children in care.

The facility is a single-story home owned by the Licensee. The inside of the home was observed to be neat, clean with ample age-appropriate materials for the children. All toxins, cleaning products, and hazardous materials were observed to be in inaccessible areas. Licensee stated that she provides all food for the children. All food that may be brought from the children’s home will be properly labeled and stored. Licensee stated that she does not transport children. There are no pets and no firearms in the home.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: NGUYEN, NHA
FACILITY NUMBER: 073409509
VISIT DATE: 08/13/2024
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There is one (1) fully charged 2A40BC fire extinguisher in the childcare room. There is one (1) working smoke detector and one carbon monoxide detector in the home. The fireplace in the family/day care room is blocked by a bookshelf, making it inaccessible to the children in care. Licensees uses highchairs and age appropriate tables and chairs for eating. There are two play yards and four cots used for sleeping. All napping equipment is clean, well maintained and in proper working order. The home is equipped with central heat and air in the home for proper ventilation.

The backyard is fully fenced, clean and has ample age appropriate materials for the children in care. There is a age appropriate toys and play equipment in the fenced off patio area for children to play safely. There is shade as well. There is also a fenced in-ground swimming pool located in the backyard. The pool has a 5ft iron fence surrounding it, that has a self latching gate.

Licensee is operating within their licensed capacity and is in ratio. Licensee’s Health and Safety training with Lead Poisoning component has been completed and Pediatric CPR and First Aid training is complete and expires 6/8/26. Licensee’s Mandated Reporter training is complete and expires 6/6/26. LPA obtained the fire/disaster drill log, log is complete with the last drill logged 4/10/24. All adults living and working in the home have obtained a criminal record clearance. All required forms are posted near the front door entrance. LPA obtained the children’s files, and facility roster. Files are complete and the roster is up to date.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: NGUYEN, NHA
FACILITY NUMBER: 073409509
VISIT DATE: 08/13/2024
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Licensee was reminded that California Law requires Licensee 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 624). Incidents must be reported within 24 hours by phone, fax, or email. The Licensee is reminded that any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. Children’s Roster must be properly maintained, and fire/disaster drill must be conducted every six (6) months and documented. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov.
Licensee was reminded that EMSA approved Pediatric CPR & First Aid training must be completed every two (2) years. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every two (2) years by visiting http://www.mandatedreporterca.com

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: NGUYEN, NHA
FACILITY NUMBER: 073409509
VISIT DATE: 08/13/2024
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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-and-resources/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. Licensee has sleep logs for each infant in care.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

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

Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Licensee Nha Nguyen.

This home will be licensed as a large family child care home as of today 8/13/24. Congratulations!
SUPERVISORS NAME: Monica Mathur
LICENSING EVALUATOR NAME: Tasha Hackett-Alexander
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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