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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416261
Report Date: 07/27/2021
Date Signed: 07/28/2021 03:17:21 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/28/2021 03:17 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, 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: 0CENSUS: 0DATE:
07/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Van Nguyen TIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elizabeth Larios met with Van Nguyen, Licensee, for an unannounced Required – 1 year annual inspection. LPA were granted access to the home by staff. LPA did not observed any children in care. LPA observed the required postings, including the facility license, near the front entrance to the home. The home has a working telephone (408) 913-5071. Days and hours of operation are Monday - Friday from 8:30AM to 5:30PM. The Licensee and her sisters, Thithutran Pham, and Thikimthoa Vo are the only adults who reside in the home. Licensee has certification for CPR and First Aid that is current and expires November 2021.

LPA did not observed a Child Care Facility Roster currently no children under care and Fire/Disaster drill log during today's inspection. No fire/disaster drills have been completed. The Licensee, has required vaccinations (MMR, Tdap, & flu). The Licensee has current Mandated Reporter Training for Child Care Workers on file (exp: 01/23/2022). LPA did not reviewed any children's files, Identification and Emergency Information (LIC 700), and Family Child Care Home Notification of Parents' Rights forms (LIC 995A) due to no children currently enrolled. The Licensee states that a child will be isolated in the front entry way of if needed because of illness or communicable disease.

Safe sleep updated: LPA discussed the new “Safe Sleep” regulations with the Licensee and provided a copy of the regulations, including the Individual Infant Sleeping Plan (LIC 9227) form to the Licensee.

REPORT CONTINUED ON FOLLOWING PAGE #2 - REPORT DATED 07/27/2021
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2021
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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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: NGUYEN, VAN
FACILITY NUMBER: 434416261
VISIT DATE: 07/27/2021
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 07/27/2021)
LPA reminded the Licensee that infants up to 12 months of age must sleep on their backs, shall be supervised while they are sleeping, and documentation of sleep checks must be kept in each infant’s file. Infants shall not be swaddled. There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. Cribs or play yards shall be free of loose articles and objects.

LPA toured the indoor and outdoor areas of the home during today's inspection. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children.There are stairs inside the home. LPA observed a secure installed gate at the bottom of the staircase. There is no fireplace inside the home. Off limit areas inside the home: living room, dining room, family room, kitchen, car garage, and the second floor. Off limit areas outside are the ADU.

LPA observed a fully charged 2A10BC fire extinguisher, no working carbon monoxide smoke detector was observed, bodies of water (water jug located in shower that has a installed cable lock to secure lid was observed in bathroom used by children), and fenced backyard. The Licensee states that she does not have any weapons in the home. The facility does not have any dogs. LPA observed a two big fish tanks & two small fish tanks which are placed in the off limit rooms (living room & dinning room). Licensee stated the two big fish tanks are very heavy and it is not possible that a child can move it. LPA observed all the tanks have lids and the lids are unreachable to the children. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children. Any poisons are in upper cabinets, garage, and bedrooms off limits and inaccessible to the day care children.
    A review of staff records on June 29, 2021 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

    REPORT CONTINUED ON FOLLOWING PAGE #3 - REPORT DATED 07/27/2021
    SUPERVISORS NAME: Anthony Studebaker
    LICENSING EVALUATOR NAME: Elizabeth Larios
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 07/27/2021
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 07/27/2021
    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, 2580 N FIRST STREET, STE. 300
    SAN JOSE, CA 95131
    FACILITY NAME: NGUYEN, VAN
    FACILITY NUMBER: 434416261
    VISIT DATE: 07/27/2021
    NARRATIVE
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    		CONTINUATION OF PREVIOUS PAGE (PAGE #2 - REPORT DATED 07/27/2021)
    Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours 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. Licensee stated does not transport children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

    LPA discussed the requirements of AB 633 with the Licensee and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and the Licensee understands the requirements. LPA also discussed "zero tolerance" related regulations with the Licensee and advised her of the assessment of an immediate $500 per day civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

    Website for provider resources: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

    LPA conducted an exit interview with the Licensee and deficiencies were issued during today's inspection.

    A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
    SUPERVISORS NAME: Anthony Studebaker
    LICENSING EVALUATOR NAME: Elizabeth Larios
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 07/27/2021
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 07/27/2021
    LIC809 (FAS) - (06/04)
    Page: 4 of 4
    Document Has Been Signed on 07/28/2021 03:17 PM - It Cannot Be Edited


    Created By: Elizabeth Larios On 07/27/2021 at 03:42 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: 07/27/2021
    Deficiency Type
    POC Due Date /
    Section Number
    DEFICIENCIES
    PLAN OF CORRECTIONS(POCs)
    Type B
    07/27/2021
    Section Cited
    HSC
    1597.543

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    		1597.543 CARBON MONOXIDE DETECTORS REQUIRED. Every family day care home for children shall have one or more carbon monoxide detectors in the facility [...]. The department shall account for the presence of these detectors during inspections.
    This requirement is not met as evidenced by:
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    		BY POC DUE DATE, 08/06/2021, Licensee agreed to purchase and install a carbon monoxide in the home. A receipt of purchase and photo of the installed carbon monoxide detector will be sent to Licensing Office to show proof of correction.
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    		Licensee was not able to show LPA that there was at least 1 carbon monoxide detector in the home during the inspection. The information on the back of the 2 detectors examined stated that the detectors present were smoke detectors only. This poses a potential risk to the health and safety of children in care.
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    Type B
    07/27/2021
    Section Cited
    CCR102417(g)(9)(A)(1)

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    		Operation of a Family Child Care Home - All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. This requirement is not met as evidenced by: Licensee states that she has not practiced fire or disaster drills with the children. This poses a potential risk to the health and safety of children in care.
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    		Licensee will submit a current fire and disaster drill log to LPA by 08/06/2021.

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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.
    SUPERVISOR'S NAME:Anthony Studebaker
    LICENSING EVALUATOR NAME:Elizabeth Larios
    LICENSING EVALUATOR SIGNATURE:
    		DATE: 07/27/2021
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 07/27/2021


    LIC809 (FAS) - (06/04)
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