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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416261
Report Date: 09/06/2023
Date Signed: 09/06/2023 06:12:29 PM

Document Has Been Signed on 09/06/2023 06:12 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:NGUYEN, VANFACILITY NUMBER:
434416261
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 5DATE:
09/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Thi Thu Trang PhamTIME COMPLETED:
03:35 PM
NARRATIVE
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On 09/06/2023 at 12:20pm, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced 1- year annual inspection. LPA was granted access to the home by resident/assistant, Thi Thu Trang Pham and explained the nature of today’s inspection. Present in the home were two assistants and five preschool children. Assistants were not comfortable speaking English and informed LPA that licensee, Van Nguyen, was out attending a meeting and will be home in some time. Licensee, Van Nguyen arrived at 1:25pm. Facility was operating within the ratio and capacity requirements of the license. Days and hours of operation are Monday to Friday, 8:30 am to 5:30 pm. The entrance to the daycare is through the left side gate. LPA observed all required posted materials near the sliding door entrance to the home. Licensee and four sisters are the adult that reside in the home.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home (408-913-5071). LPA observed sufficient materials, toys, and play equipment for the day care children. Furniture, such as tables, chairs, and shelves, are in good condition. Children were napping on cots during today's inspection. The floors were free of tripping hazards with toys put away in bins. The home has central heating, wall air conditioner and ventilation for comfort of children. The home is two story and LPA observed barricaded stairs during today's inspection. Off limit areas inside the home: entire upper level, living room, dining room, kitchen, family room and attached garage. LPA observed a screened fireplace in the off limit family room. Off limit areas outside the home: right side section including an ADU. Licensee stated that the ADU in the backyard does not have any residents at present. Backyard is fenced and both sides of the home are gated. The outdoor space and play equipment were observed to be age appropriate and free of hazards. There are no bodies of water observed. LPA observed that the bathroom used by children was in operating condition. Toilets and faucet are clean and operable. The shower area is free of any hazards.

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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Document Has Been Signed on 09/06/2023 06:12 PM - It Cannot Be Edited


Created By: Farida Raja On 09/06/2023 at 02:49 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: NGUYEN, VAN
FACILITY NUMBER: 434416261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. Licensee did not have a currect Fire Drill log.
POC Due Date: 09/20/2023
Plan of Correction
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Licensee will conduct and document a fire drill and submit proof to LPA by Plan of Correction date of 09/20/2023.

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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/06/2023 06:12 PM - It Cannot Be Edited


Created By: Farida Raja On 09/06/2023 at 02:49 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: NGUYEN, VAN
FACILITY NUMBER: 434416261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above for 1 out of 3 staff which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2023
Plan of Correction
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Licensee will submit proof of immunizations for MMR (measles ), Tdap (Pertussis) and Influenza/ statement declining influenza for staff, S2, by Plan of Correction date of 09/20/2023.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview 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 have a current facility roster.
POC Due Date: 09/20/2023
Plan of Correction
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Licensee will submit a current facility roster to LPA by Plan of Correction dat of 09/20/2023.
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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023


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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NGUYEN, VAN
FACILITY NUMBER: 434416261
VISIT DATE: 09/06/2023
NARRATIVE
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LPA observed a fully charged 2A10BC fire extinguisher in the play room and working smoke/carbon monoxide detector. The Licensee states that she does not have any weapons or pets in the home. LPA observed a large fish tank in the off limit family room. All detergents, cleaning compounds, poisons, medications, sharp objects and other similar items were observed to be stored inaccessible to children. Licensee understands that smoking is prohibited in the home.

Drinking water is readily available for children in the home via individual water bottles. Licensee states that parents provide breakfast. Licensee states that she provides lunch and snacks to the children in care. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored or refrigerated. Licensee states that a child will be isolated in the living room if necessary due to illness or communicable disease.

Licensee did not have an current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. Licensee will submit an updated roster and will conduct and document a fire drill and submit to LPA. Licensee stated that she would like to add a co-licensee as well as increase capacity. LPA informed licensee to submit a request to licensing along with an LIC 279- Application for Family Child Care License.

Children file review was completed and found to be current and up to date. Five ( 5) children’s files were reviewed during today's inspection. Licensee does not have liability insurance for the day care and issues the Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282). LPA observed the LIC 9224 in file for all children enrolled.

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.

LPA reviewed 3 staff files (Licensee and 2 adult assistants) for the required forms. A review of staff records

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NGUYEN, VAN
FACILITY NUMBER: 434416261
VISIT DATE: 09/06/2023
NARRATIVE
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indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee has current Pediatric CPR/First Aid certification (expires 11/02/2023). Licensee and one staff have the required immunization in file for measles, pertussis and influenza/ statement declining influenza. Staff (S2) did not have immunization's on file.
Licensee's Mandated Reporter Training expires on 07/31/2024. Staff (S1 and S2) have not completed Mandated Reporter Training's as it is not offered in Vietnamese. Licensee understands the training is mandatory to all Licensees and adults in the home in contact will children and requires renewal every two years. LPA referred the Licensee to the training website: www.mandatedreporterca.com for additional information on the online training.

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.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during 80% of the operating hours of the day care and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 8 children in the home at any time.

LPA discussed "zero tolerance" related regulations which includes the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. A $500 immediate civil penalty is assessed for serious violations such as absence of supervision, accessible bodies of water, accessible firearms, refused entry of licensing staff, presence of an excluded person, and violations that result in illness or injury. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

Licensee is encouraged to visit the Department’s website at https://cdss.ca.gov/inforesources/child-care-licensing to access general updates, resources for providers, regulations, adoptions of new laws, pay annual fees etc. Incidental Medical Services (IMS) policy was discussed. Licensee is not providing medication to children at this time. For IMS information see PIN

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SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: NGUYEN, VAN
FACILITY NUMBER: 434416261
VISIT DATE: 09/06/2023
NARRATIVE
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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 states that she does not transport any day care children. LPA reminded Licensee that if she decides to transport children, children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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.

During the exit interview, licensee confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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.

Three Type B deficiencies were cited today on the attached LIC 809D pages. Appeal rights were printed and provided to Licensee. LPA reminded Licensee that failure to correct deficiencies by Plan of Correction Due Date may result in penalties of $100 per day per violation.

Exit interview conducted and report was reviewed with the licensee, Van Nguyen.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Farida Raja
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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