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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416193
Report Date: 04/06/2022
Date Signed: 04/12/2022 08:34:36 AM

Document Has Been Signed on 04/12/2022 08:34 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:DOAN, HONG LOANFACILITY NUMBER:
434416193
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
04/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Hong Loan DoanTIME COMPLETED:
05:55 PM
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Licensing Program Analyst (LPA) Dung Mac met with Hong Loan Doan, Licensee, for unannounced Required – 1 year annual inspection. LPA observed eight preschool day care children in the home during today's inspection.

LPA observed the required postings, including the facility license, at the front entrance to the home. Days and hours of operation are Monday - Friday from 7:00AM to 5:00 PM. Adults who reside in the home are Licensee and one adult resident (Kim Anh Doan).

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on January 31, 2020. Licensee does not have liability insurance for the day care and thus issues the Affidavit Regarding Liability Insurance for Family Child Care Home to all families. Licensee stated that she does not transports children.

LPA toured the indoor and outdoor areas of the home with the Licensee during today's inspection. The facility is a 2-story house. The home is clean, orderly, and safe for the day care children. The entire 2nd floor is off-limit. LPA observed a child safety gate installed at the base of the staircase to prevent children from accessing the stairs to go to the second floor.

Off-limit areas on the 1st floor: Kitchen, Living Room, Garage, and two of the three restrooms. LPA observed kitchen has a gate. LPA observed front yard and backyard are enclosed by fence. Licensee stated that the gates at the entrance of the premises are locked all the time and are opened only during drop off time and pick up times during daycare hours.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Dung Mac
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOAN, HONG LOAN
FACILITY NUMBER: 434416193
VISIT DATE: 04/06/2022
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Licensee states that backyard and detached prayer hall are off limit. LPA observed locked gates on the right side of the home that prevents children from going to the off-limit areas. The front yard is used for outdoor activity space. Licensee understands that children must be supervised at all times while outdoors. No bodies of water were observed.

Licensee has proper heating/cooling and ventilation in the home. LPA observed there are safe and age appropriate toys for the children in the home. Licensee has a designated area in the home where a child(ren) can be isolated if exhibiting signs of illness.

LPA observed the home has working smoke/carbon monoxide detectors (tested by the Licensee during today's tele-inspection). LPA observed a fully charged 3A40BC fire extinguisher. LPA informed Licensee that smoking is prohibited in the home during daycare hours. Licensee understands and states that nobody smokes in the home.

The Licensee states that she does not have any pets or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. LPA observed that poisons are stored in a locked cabinet in the kitchen.

Licensee states that the facility is not providing Incidental Medical Services. Licensee has a first aid kit in the home which includes a touch less thermometer.

Licensee has current CPR and First Aid certifications. Licensee has the required vaccines (MMR, Tdap, & influenza - opt out). Licensee has limited English proficiency and since the AB1207 Mandated Reporter Training is not available in her primary language (Vietnamese), Licensee is exempt from the requirement to complete the Mandated Reporter Training at this time.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Dung Mac
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: DOAN, HONG LOAN
FACILITY NUMBER: 434416193
VISIT DATE: 04/06/2022
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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.

LPA reviewed eight children's files and one staff (Licensee) file. All children's files are missing PM 286 - Immunization Records.



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/inspection-process.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing updates and regulations.



Type B deficiencies were cited today. Exit interview conducted and report was reviewed with the licensee, Hong Loan Doan. Appeal Rights was given to Licensee. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Dung Mac
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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Document Has Been Signed on 04/12/2022 08:34 AM - It Cannot Be Edited


Created By: Dung Mac On 04/06/2022 at 05:10 PM
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: DOAN, HONG LOAN
FACILITY NUMBER: 434416193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
The licensee shall document the drills, including the date and time of each drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the Fire and Disaster Drill Log was not conducted at least once every months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/12/2022
Plan of Correction
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Licensee will be conducting the drill and send a copy of the log to Licensing.
Type B
Section Cited
CCR
102418(g)(1)
Licensee shall document and update each child's immunizations and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, there was no copy of immunization record in children's files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2022
Plan of Correction
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Licensee will submit a copy of PM-286 for all children to Licensing.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Dung Mac
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022


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