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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416386
Report Date: 07/20/2021
Date Signed: 07/20/2021 04:30:07 PM

Document Has Been Signed on 07/20/2021 04:30 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:PIMSAKUL, MATHWEE & KENDRAFACILITY NUMBER:
434416386
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
07/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Matt PimsakulTIME COMPLETED:
04:07 PM
NARRATIVE
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On 7/20/2021 at 1:48pm: Licensing Program Analyst (LPA) Pete Hernandez met with Licensee, Mathwee and Kendra Pimaskul and conducted an unannounced Required 1 year inspection. The adults that reside in the home are: the two Licensees'. Licensees have 4 minor children under 10 years of age. Licensees provide respite care and are foster parents through Santa Clara County. Licensee's currently do not have foster care children living in the home. Santa Clara County Resource Family number: 999637RFA.

Days and hours of operation will be Monday - Friday from 7:00AM to 6:00 PM. CPR and First Aid certifications are current with an expiration date of 6/21/2023. Licensees rent the home. Licensees use the Affidavit Regarding Liability Insurance form to inform parents that they do not carry daycare insurance.

LPA toured the indoor and outdoor areas. The home is clean and orderly. Off limit areas in the home: bedrooms 1, 2, 4 and garage. The gated backyard deck is the only on-limit area outside the home. LPA observed a fully charged 2A10BC fire extinguisher, working smoke detector, fire pull stations ,functioning carbon monoxide detector, two barricaded fire places in the living and family room, fenced backyard, and no bodies of water. LPA observed sufficient materials, toys, and play equipment for the daycare children. Per Licensee, there are no weapons in the home. Applicants have one fully vaccinated dog. LPA reminded Licensees that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes. Property Owner/Landlord Consent (LIC 9149) and Property Owner/Landlord Notification (LIC 9151) are on file.

Licensees state that they will use positive discipline and redirection as forms of discipline. Applicants understand that children's personal rights should not be violated; including no corporal punishment.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 07/20/2021:
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2021
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: PIMSAKUL, MATHWEE & KENDRA
FACILITY NUMBER: 434416386
VISIT DATE: 07/20/2021
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 7/20/2021):

LPA informed 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

The Licensee states that she does not transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.


Supervision of children was discussed with the Licensee. Licensee understands that she must be present in the home at least 80 percent of the hours the day care is in operation and ensure that the children are supervised at all times. The Licensee understands her capacity options. The Licensee states that she does not transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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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: PIMSAKUL, MATHWEE & KENDRA
FACILITY NUMBER: 434416386
VISIT DATE: 07/20/2021
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Last fire drill was done 7/19/2021. LPA informed Licensee that fire/disaster drills must be practiced at least once every six months and documented. Licensee is compliant.

Both Licensees Mandated Reporter certificates expired 5/18/2021.

LPA went over Reg 102425(j) and (j)(2)(D) regarding infant care and LIC 9227 (Infant Sleeping Plan). LPA Provided a copy.The provider shall supervise infants while they are sleeping.

LPA observed all required postings on the wall next to the front door.

Deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. A copy of this report and appeals rights were discussed and left with the Licensee, Kendra Pimsakul, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2021
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Document Has Been Signed on 07/20/2021 04:30 PM - It Cannot Be Edited


Created By: Pietro Hernandez On 07/20/2021 at 02:25 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: PIMSAKUL, MATHWEE & KENDRA
FACILITY NUMBER: 434416386

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2021
Section Cited
HSC
1596.8662(b)(1)

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On or before March 30, 2018, a person who on, January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training […] and shall complete renewal […] every two years […] This requirement is not met as evidenced by:
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BY POC DUE DATE Licensee and Assistant Provider will complete the training and send a copy of the Certificate of Completion to Licensing Office. LPA provided the web address https://www.mandatedreporterca.com to access the required training.
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Per LPA's review of files, Licensees do not have Mandated Reporter Training per AB1207. Licensee stated she was unaware of the requirement. This poses a potential risk to the health and safety of children 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:Sandy Knight
LICENSING EVALUATOR NAME:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2021


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