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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416261
Report Date: 09/03/2026
Date Signed: 09/03/2026 05:39:06 PM

Document Has Been Signed on 09/03/2026 05:39 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, VANFACILITY NUMBER:
434416261
ADMINISTRATOR/
DIRECTOR:		VAN NGUYENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 913-5071
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
09/03/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Van Nguyen and Thi Kim Thoa VoTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
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On 09/03/2026, Licensing Program Analysts (LPAs), Farida Raja and Sara Mulugeta, conducted an unannounced annual inspection. LPAs were granted access to the home by assistant, Thi Kim Thoa Vo and explained the nature of today’s inspection. Present in the home were two assistants (S2 and S3) and six children including one infant and five preschool children. Licensee, Van Nguyen arrived during the course of the inspection. Facility is operating within the ratio and capacity requirements of the license. Current days and hours of operation are Monday to Friday, 8:30 AM to 5:30 PM. LPAs observed all required postings near the front entrance. Per Licensee, six adults and no minor children reside in the home and Accessory Dwelling Unit (ADU).

LPAs toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. LPAs 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 observed to be napping in the living room during today's inspection. The home has central heating/cooling and ventilation for comfort of children. The home is two story and LPAs observed barricaded stairs during today's inspection. LPA reviewed the current facility sketch and confirmed that the living room, family room, nook, dining area and downstairs bathroom are used for providing care and are accessible to children. Off limit areas inside the home: play room (as labelled on facility sketch), entire upper level and attached garage. LPAs observed a screened fireplace in the on limit family room. The bathroom used by children was in operating condition. Toilets and faucet are clean and operable. The shower area is free of hazards.

Backyard is fenced and both sides of the home are gated. The outdoor space and play equipment were observed to be age appropriate.

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Gladys Kuizon
Farida Raja
DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2026
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.

LIC809 (FAS) - (09/23)
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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, VAN
FACILITY NUMBER: 434416261
VISIT DATE: 09/03/2026
NARRATIVE
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 During the walk through of the outdoor area LPAs observed the child gate barricading the ADU was not in place making the gardening tools and herbicide which was stored on the floor accessible to children. The storage shed was observed to have a twist lock midway through the height of the door. LPAs advised Licensee to place an additional lock as the shed is used to store paint, insect killer sprays, fertilizers, gardening tools and other items that could pose a hazard to children. LPAs observed two planters, one with a plant inside, that have collected water and a transparent tank with very little water in the base that is used for turtles. LPAs reminded Licensee of the Department's zero tolerance policy for bodies of water. Licensee stated that the planters are used to collect rain water to water plants and she will dispose the water. LPAs also observed open bags of water softener with the salt pellets spilling out. LPA informed Licensee that these could pose a hazard if ingested by children. LPAs also observed strips of unfinished wood in the yard with some used to create a plant border and a wooden rack to hold plants. LPAs informed Licensee that splinters and the nails on the wooden strips could pose a hazard to children in care and need to be removed or placed in an off limit area. LPAs advised Licensee to scan the outdoor area for hazards prior to allowing access to children. Children were not observed using the backyard during today's inspection.

LPAs observed a 3A40BC fire extinguisher in the family room and working smoke/carbon monoxide detector. LPAs reminded Licensee that fire extinguishers needs to be service annually and proof of purchase or service tag needs to be maintained for review. Licensee states that she does not have any weapons in the home. Licensee has fish and turtles as pets. LPAs observed a large fish tank in the family room. All detergents, cleaning compounds, poisons, medications, sharp objects and other similar items were observed to be stored inaccessible to children. LPAs reminded Licensee that all sharps and medications need to be stored in high cabinets out of reach of children. Licensee understands that smoking is prohibited in the home.

Licensee was reminded to notify the Department before making any alterations or additions to the home or grounds and when any change from an area of the family child care home previously identified as off limits is changed to an area where care and supervision will be provided to children in care.

Drinking water is readily available for children in the home via individual water bottles. Licensee states that facility provides snack to the children and parents provide meals. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored or refrigerated.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
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, VAN
FACILITY NUMBER: 434416261
VISIT DATE: 09/03/2026
NARRATIVE
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LPA reviewed a current children's roster and fire drill log during today's inspection. Last fire drill was conducted on 05/06/2026 which is within the 6-month requirement for facilities. LPA obtained copy of the children's roster.

LPA reviewed a sample of four children’s files and observed files were complete with emergency information as required. Licensee has not been conducting 15 minute sleep checks for one infant (C1) in care. 1 out of 4 children was observed to be missing their immunization record. Licensee stated that both children started in care this week. They will start conducting sleep checks for C1 and are in the process of obtaining the immunization record for C2. C2 was observed to have all other required documents. LPA provided Licensee with a copy of the 15 minute sleep log and reminded Licensee that sleep checks need to be conducted for all infants under 24 months of age.


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 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 and assistant have the required Pediatric CPR/First Aid and Mandated Reporter Training's. Licensee and staff have the required immunization in file for measles, pertussis and influenza/ statement declining influenza.

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.

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NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
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, VAN
FACILITY NUMBER: 434416261
VISIT DATE: 09/03/2026
NARRATIVE
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Licensee understands that children's personal rights should not be violated; including no corporal punishment. Children have personal rights that cannot be waived or abridged regardless of consent or authorization from the child’s authorized representative.

LPA discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to resources such as forms, regulations, Provider Information Notices (PINs), and Quarterly Updates. LPA discussed Reporting Requirements as outlined in the regulations (Section 102416.2).

Supervision of children was discussed with Licensee, and she understands that she or a qualified adult must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time and a qualified assistant must be present. Licensee understands in absence of a helper her license capacity is reduced to 8 and ratio (age of the children) must be observed.



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.

Incidental Medical Services (IMS) policy was discussed. Licensee states that she is not providing medication or IMS to children at this time. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. Licensee states that a child will be isolated in the family room/living room, away from other children, if necessary, due to illness or communicable disease until parent pick up. 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. 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: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
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, VAN
FACILITY NUMBER: 434416261
VISIT DATE: 09/03/2026
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Per Title 22, Division 12, of the California Code of Regulations, one Type A deficiency was cited.

LPA Raja informed licensee, Van Nguyen that this report dated 09/03/2026 documents one Type A citation which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care. Also, LPA Raja informed the licensee to provide a copy of this licensing report dated 09/03/2026 that documents any Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

Appeal rights and LIC 9224 (Acknowledgement of Receipt of Licensing Reports) were provided to Licensee. Exit interview conducted and report was reviewed with Licensee, Van Nguyen. 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.


A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.

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.
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Farida Raja
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2026 05:39 PM - It Cannot Be Edited


Created By: Farida Raja On 09/03/2026 at 03:25 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: 09/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

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 an immediate health, safety or personal rights risk to persons in care. During the walk through of the outdoor area LPAs observed the child gate barricading the ADU was not in place making gardening tools and herbicide which was stored on the floor accessible to children. LPAs observed two planters, one with a plant inside, that have collected water and a transparent tank with very little water in the base that is used for turtles. LPAs reminded Licensee of the Department's zero tolerance policy for bodies of water. LPAs also observed open bags of water softener with the salt pellets spilling out could pose a hazard if ingested by children. LPAs observed strips of unfinished wood in the yard with some used to create a plant border and a wooden rack to hold plants. LPAs informed Licensee that splinters and the nails on the wooden strips could pose a hazard to children.
POC Due Date: 09/04/2026
Plan of Correction
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Licensee to submit a written plan of correction along with picture proof to LPA by plan of correction date of 09/04/2026.
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.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Farida Raja
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2026


LIC809 (FAS) - (06/04)
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