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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415162
Report Date: 05/08/2025
Date Signed: 05/08/2025 12:21:52 PM

Document Has Been Signed on 05/08/2025 12:21 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:NGUYEN, NGUYENFACILITY NUMBER:
434415162
ADMINISTRATOR/
DIRECTOR:		NGUYEN NGUYENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 564-3617
CITY:SAN JOSESTATE: CAZIP CODE:
95111
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
05/08/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Nguyen NguyenTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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At 8:33 AM, Licensing Program Analysts (LPAs) Syeda Bahar and Andy Yang arrived at the facility. At 8:35 AM, LPAs were greeted by a staff. LPAs identified with proper identification to the staff. Staff stated that Licensee, Nguyen (Kevin) Nguyen was not home. The staff did not granted access to the LPAs to allow entrance into the day care. LPA Syeda called Licensee at 8:40 AM. Licensee stated (over the phone) that he is not home at this time, and he will be back soon. At 9:53 AM Licensee arrived at the facility and opened the locked front door of the house. LPAs were granted entrance to the facility by Licensee at 9:00 AM. LPA Syeda explained the purpose of today’s visit to licensee. The purpose of today’s visit is to conduct an unannounced Case Management - Annual Continuation Inspection (visit date 03/06/2025). Present for this inspection were Licensee, one staff, five preschool age children and one infant. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday to Friday, 8:00 AM to 6:00 PM. The day care is a single family home. The home is neat and clean with heating and ventilation for safety and comfort. LPAs observed all REQUIRED forms are posted and visible for public review.

On-limits area: Day care room, kitchen, living room, one bathroom in the hallway.
Off-limits area: Home Office, four bedrooms, two bathrooms, and backyard. The off-limit area is inaccessible by closed doors, barricade and visual supervision.
Isolation area: Living room

Licensee stated that the backyard is off limit. LPAs observed there were dogs in the backyard. LPAs observed play structures in the right side of the backyard. The backyard is fenced. There have been no changes from the areas previously identified as OFF LIMITS or alterations to existing building or grounds. There are ample age-appropriate toys that appear to be safe and in good condition. There are no bodies of water.

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NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NGUYEN, NGUYEN
FACILITY NUMBER: 434415162
VISIT DATE: 05/08/2025
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All hazardous materials and toxins are kept out of the reach of children. Licensee states that any poisons are stored inside the cabinet under the sink in the kitchen. LPA Syeda observed that the cabinet under the sink is locked. LPAs reminded Licensee that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes.

The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The Licensee CPR and First Aid certificate is current, completed on 10/12/2023 and expires on 10/12/2025. Licensee completed the Mandated Reporter Training for Child Care Providers on 10/22/2024 and expires on 10/22/2026 and a copy of the certification is on file. Licensee was reminded of Mandated Reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the licensee’s immunization is on file. Per Licensee, there are no firearms in the home. The Licensee conducts and documents fire and disaster drill every six months. Personnel records are available for review and contain all required forms. Child’s records are available for review. LPA Syeda observed the children records were missing the form LIC 9224 - Acknowledgement of Receipt of Licensing Report.

The crib that was inspected meet the safety standards. The crib does not hinder entrance or exit to and from the space where infants are sleeping. At 9:05 AM LPA Syeda observed there were blankets in the crib. At 9:37 AM LPA Andy Yang observed an infant was laying in the crib with blankets next to the infant in the crib. LPA reminded the licensee that cribs must be free from all loose articles including blankets. Licensee removed the blanket at time of inspection. The mattress in the crib or play yard is firm and covered with a fitted sheet that is appropriate, fits tightly, and overlaps the underside of the mattresses. Each infant’s bedding is used for them only and cleaned weekly or before use by another infant. Each infant under 12 months of age has an Individual Infant Sleeping Plan maintained in the file signed and dated by the infant’s authorized representative, including the infant’s sleeping position and documentation of 15-minute checks while sleeping. Forms of discipline to be used by Licensee are redirecting and talking with the child. Licensee understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature.
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NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NGUYEN, NGUYEN
FACILITY NUMBER: 434415162
VISIT DATE: 05/08/2025
NARRATIVE
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Also, discussed with the Licensee was isolation of sick children, supervision of children, staffing ratio and capacity, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute. Licensee states that they provide breakfast, lunch and snacks (AM/PM) everyday to the daycare children. Licensee was reminded that all food brought from home should be labeled with each child's name and properly stored. Licensee has a first aid kit in the home which includes a touch less thermometer.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-andresources/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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NGUYEN, NGUYEN
FACILITY NUMBER: 434415162
VISIT DATE: 05/08/2025
NARRATIVE
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During the exit interview, the Licensee, Nguyen (Kevin) Nguyen, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Megan's Law was checked on 03/05/2025.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.


During today’s inspection, three (3) “Type B” deficiencies are issued on attached 809-D. Appeal rights provided.

Type B
  • Missing LIC 9224 from children's file.
  • Inspection Authority, staff refuse access to day care home to LPAs after proper identification
  • Observation of infant laying in the crib next to a blanket.




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

Exit interview conducted and report was reviewed with the Licensee, Nguyen (Kevin) Nguyen.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Syeda Bahar
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 05/08/2025 12:21 PM - It Cannot Be Edited


Created By: Syeda Bahar On 05/08/2025 at 11:00 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: NGUYEN, NGUYEN
FACILITY NUMBER: 434415162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPAs observed there were blankets, pillow and toys in the crib and one infant was sleeping there.
POC Due Date: 05/08/2025
Plan of Correction
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Licensee will ensure that the crib or play yard is free from all loose articles and objects. Licensee will remove the blankets, pillows, and toys from the crib,
Request Denied: Appeal Not Submitted Timely
Type B
Section Cited
CCR
102391(c)
Inspection Authority of the Department
(c) The licensee shall permit the Department to inspect any part of the family child care home in which family child care services are provided or to which children have access.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. At time of arrival at 8:35 AM the staff did not granted access to Licensing Program Analysts (LPAs) in the day care.
POC Due Date: 05/22/2025
Plan of Correction
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By the Plan of correction due date 05/22/2025, Licensee will submit the written statement of understanding of Title 22 regulations; inspection authority of the department and the staff is aware of the inspection authority of the department, to the department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:
Syeda Bahar
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 05/08/2025 12:21 PM - It Cannot Be Edited


Created By: Syeda Bahar On 05/08/2025 at 11:20 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: NGUYEN, NGUYEN
FACILITY NUMBER: 434415162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8595(c)(1)
(c)(1) A licensed child day care facility shall provide to the parents or guardians of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee did not provide the LIcensening Report to the parents of currently and newly enrolled children. Licensee did not obtained the LIC 9224 for Typa A cited on 11/06/2024.
POC Due Date: 05/22/2025
Plan of Correction
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By the Plan of Correction (POC) due date, 05/22/2024, Licensee will obtain the signed copy of LIC 9224 for all currently and newly enrolled children in the day care. Licensee will provide signed copies of the form LIC 9224 to the department as a proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:
Syeda Bahar
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2025


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