<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416586
Report Date: 11/01/2024
Date Signed: 11/01/2024 03:22:30 PM

Document Has Been Signed on 11/01/2024 03:22 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, ANH DAOFACILITY NUMBER:
434416586
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/01/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Anh NguyenTIME VISIT/
INSPECTION COMPLETED:
03:37 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/01/2024, at 1:00 PM, Licensing Program Analysts (LPAs) Andy Yang and Mandeep Kaur, met with Applicant, Anh Nguyen to conduct an announced Pre-licensing inspection for a Small Family Child Care Home. Present for this inspection is Applicant, Son, and Niece. Niece was present for some translation, but does not live in the home. The home was toured to conduct a Health and Safety Inspection. Days and hours of operation are from Monday to Friday 8:00 AM to 6:00 PM. Children enrolled will be from age 0 months to 5 years old.

The home is Single Family Home. The home consists of Living Room, Kitchen, Bathroom, Bedroom 1, Bedroom 2, Master Bedroom, Master Bathroom, Backyard, Side yard and Garage. The home is neat and clean with heating and ventilation for safety and comfort. The ON LIMIT AREAS are Living Room, Bathroom, and Backyard. The OFF LIMIT AREAS are Bedroom 1, Bedroom 2, Master Bedroom, Master Bathroom, Garage, and Left Side yard. which will be inaccessible by closed and/or locked doors and visual supervision. The ISOLATION AREA will be right side of living room. The outdoor play area is free from defects or dangerous conditions and is fenced. There are ample age-appropriate toys that appear to be safe and in good condition. There are no pools, hot tubs, or any other bodies of water. All hazardous materials and toxins are kept out of the reach of children. LPA reminded the Applicant that adult care products needs to be inaccessible to children. Applicant states that any poisons are stored in master bathroom and garage which is OFF LIMITS. LPA reminded Applicant that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes.

The home has a fully charged 2A10BC fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The Applicant CPR and First Aid certificate is current and expires 8/21/2026. Applicant completed the Mandated Reporter Training for Child Care Providers on 8/21/2024 (Expires 8/21/2026 and a copy of the certification is on file. Applicant was reminded of Mandated reporter Training (AB1207) and CPR/First aid certifications needs to be renewed every two years. A copy of the Applicant’s immunization is on file. Per Applicant, there are no firearms in the home.

***Continue Page 2***
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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 4
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, ANH DAO
FACILITY NUMBER: 434416586
VISIT DATE: 11/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***Page 2***
Applicant states that she will not administer any medication to the children at this time. Applicant states that a child will be isolated in the ISOLATED AREA if necessary due to illness or communicable disease. Applicant has a First Aid kit with a touchless thermometer in the home. Also discussed with Applicant the requirements for reporting suspected child abuse, unusual incidents/injuries, and heat related illnesses.

Forms of discipline to be used by Applicant are redirecting and talking with the child. Applicant understands that children's personal rights should not be violated, including but not limited to, no corporal punishment, children are treated with dignity, receive safe, healthful, and comfortable accommodations, interference with eating, intimidation, or other actions of a punitive nature. LPA informed the Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

The applicant provided proof of control of property, and is on file.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 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) or (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.



Applicant, Anh Nguyen was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

LPA reviewed with the Applicant, the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Pre-licensing Entrance Checklist – Family Child Care Homes (LIC 9280) was provided to the Applicant.

***Continue Page 3***

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
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, ANH DAO
FACILITY NUMBER: 434416586
VISIT DATE: 11/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***Page 3***

LPA discussed the safe sleep regulations with Applicant, Anh Nguyen, and discussed the Child Care Licensing Safe Sleep webpage at:https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource. LPA also informed Applicant 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.

On this date, 9/18/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

*** Continue Page 4***
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
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, ANH DAO
FACILITY NUMBER: 434416586
VISIT DATE: 11/01/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***Page 4***

Exit interview conducted and report was reviewed with the Applicant, Anh Nguyen. LPA advised the Applicant that a Small Family Child Care Home license will be approved upon completion of the following, and Licensing Program Manager's approval.
  • Covering/screened fireplace
  • Updated Sketch of backyard with on and off limits
SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4