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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415162
Report Date: 12/15/2021
Date Signed: 12/15/2021 10:15:09 AM

Document Has Been Signed on 12/15/2021 10:15 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PHAN, NGAN & NGUYEN, NGUYENFACILITY NUMBER:
434415162
ADMINISTRATOR:NGAN & NGUYENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(669) 226-0398
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 9DATE:
12/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Nguyen, NguyenTIME COMPLETED:
10:30 AM
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Licensing Program Analysts (LPAs) Janette Cruz and Mel Matos met with Nguyen Nguyen, Licensee, and conducted an unannounced case management inspection in response to a request to remove Ngan Phan, Co-Licensee from the facility license. Also present in the home during today's inspection were two staff assistants: Minh Truong and Thi Hoang and 9 day care children (3 infants, Nguyen's infant child, and 5 preschool).

LPAs reviewed two staff files and 12 children's files during today's inspection.

LPA's advised Nguyen that a follow up inspection will be required.

No deficiencies issued during today's inspection.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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