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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500607
Report Date: 06/16/2022
Date Signed: 06/16/2022 12:55:51 PM

Document Has Been Signed on 06/16/2022 12:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:MA, LINHFACILITY NUMBER:
394500607
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/16/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Linh Ma TIME COMPLETED:
01:10 PM
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On June 16, 2022 at approximately 9:45AM , Licensing Program Analyst (LPA) Stacey Williams met with Applicant Linh Ma for the purpose of a pre-licensing inspection. Criminal record clearances were verified.

LPA and Applicant toured the single-story home. The facility consists of 3 bedrooms,1 office, 2 bathrooms, family room, living room, dining room, laundry room, kitchen, and garage. Off limit areas: three bedrooms, gated left side of the backyard, meshed fence pool area, laundry room and the garage.

Applicant owns the home with her husband. A copy of control of property deed is on file. Applicant has completed the required Preventative Health and Safety course which includes 1 hour of nutrition and lead prevention training. LPA provided blank forms required for staff records as well as for children's records including LIC 9227- Individual Infant Sleeping Plan. At the right entry of the facility Applicant has a designated Licensing Area where required forms such as Parent's Rights Notification, Emergency Disaster, Earthquake Preparedness Checklist and the Facility Sketch is posted. This area is where Licensing forms/posters will be placed for parental review.

LPA and Applicant toured the facility. The backyard is fenced. There is an above ground pool in the backyard that is surrounded by mesh fencing that meets regulation standards. Applicant stated that 100 percent supervision will be provided to children while outside in the backyard. Applicant stated there is a possibility that children will be escorted the local park that is across the street from the home as well as utilize outdoor front yard space for play. Applicant shall have 100 percent supervision while children are being escorted to the park, while at the park, and while playing in the front yard.

** Continued on subsequent page LIC 809C **

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2022
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: MA, LINH
FACILITY NUMBER: 394500607
VISIT DATE: 06/16/2022
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Applicant stated there are no weapons in the home. Applicant understands the smoking prohibition for childcare.

LPA observed the kitchen cabinets are properly secured. All medications and knives are stored and inaccessible.

LPA observed a 2A10BC fire extinguisher. LPA observed an operational smoke detector and carbon monoxide detector in the home that meet regulatory standards. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction.


LPA and Applicant discussed Safe Sleep Regulations and Covid-19 Guidance for Childcare Providers.

LPA discussed the safe sleep regulations with Applicant 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 Applicant 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.



Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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


SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: MA, LINH
FACILITY NUMBER: 394500607
VISIT DATE: 06/16/2022
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Applicant has completed the required AB1207 Mandated Reporter training. Applicant understand that the training must be completed once every two years, training is accessible at www.mandatedreporterca.com. CPR/First Aid certification is current and expires 2/2024.

Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months. Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPM explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within seven days to remain in compliance.

LPA reviewed with Applicant the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

Entrance Checklist was provided to the applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.




This facility evaluation report was reviewed and discussed with the Applicant.

Effective June 16, 2022, Applicant is approved for a license to serve up to either 8 children, two (2) of which must be at least 6 years of age and no more than two (2) may be infants; or 6 children, three (3) of which may be infants; or 4 infants only. Infants are children under the age of 2 years.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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