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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416261
Report Date: 07/20/2023
Date Signed: 07/21/2023 09:00:33 AM

Document Has Been Signed on 07/21/2023 09:00 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
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: 8CENSUS: 9DATE:
07/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Van Phuoc NguyenTIME COMPLETED:
05:00 PM
NARRATIVE
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On 07/20/2023, Licensing Program Analysts (LPAs), Farida Raja and Marilou Monico, conducted an unannounced Case Management Visit to verify adult (P1) does not reside at the facility since she does not have criminal background clearance. On arrival, LPAs were greeted by adult (P2) who could not speak English and called Licensee, Van Nguyen, who stated that she will be home in 20 minutes. P2 granted entry to LPAs.

Present during the visit were 9 children (7 preschool age and 2 school age) and 2 teachers. Licensee was operating over capacity requirements of the small family childcare license. Licensee arrived at 3:30pm. LPAs verified all staff and adults residing in the home had fingerprint clearances and that adult P1 was not residing in the home. LPAs requested children's files and found them to be incomplete or missing for children C3-C9.
One Type A and one Type B deficiency were cited on the attached LIC 809D pages as a result of today's inspection. Appeal rights and LIC 9224 were printed and given to Licensee.

Due to the issuance of a Type A Citation during today's inspection, a copy of this Licensing Report must be given to each existing parent by the end of today or next day child is in care, and to any newly enrolled parents/guardians enrolled over the next 12 months from the date of this report. In addition, a copy of the LIC 9224 Acknowledgement of Receipt of Licensing Reports must be signed by each parent and kept in each child's file. 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: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 07/21/2023 09:00 AM - It Cannot Be Edited


Created By: Farida Raja On 07/20/2023 at 04:11 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: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/21/2023
Section Cited
CCR
102416.5(a)

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102416.5 (a) Staffing Ratio and Capacity
The capacity specified on the license shall be the maximum number of children for whom care may be provided at any one time.

This requirement is not met as evidenced by:
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Licensee will submit a written plan of correction to LPA by POC date of 07/21/2023.
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Upon arrival to the family child care home (FCCH), LPA's observed 9 children in care including 7 preschool and 2 school age, which poses an immediate riskt to the health, safety, and personal rights of children in care.
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Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/21/2023 09:00 AM - It Cannot Be Edited


Created By: Farida Raja On 07/20/2023 at 04:41 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: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/28/2023
Section Cited
CCR
102419(a)

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102419 (a) Child's Records
The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
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Licensee will maintain complete files with required forms for each child and notify LPA of completion by POC date of 07/28/2023.
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Children's files for children C3-C9 were incomplete or missing which poses a potential health, safety or personal rights risk to persons in care.
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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:Gladys Kuizon
LICENSING EVALUATOR NAME:Farida Raja
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
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