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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416736
Report Date: 10/13/2021
Date Signed: 10/13/2021 11:02:10 AM

Document Has Been Signed on 10/13/2021 11:02 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PHAM, PAULINAFACILITY NUMBER:
434416736
ADMINISTRATOR:PAULINA PHAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 260-6349
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
10/13/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Paulina PhamTIME COMPLETED:
11:10 AM
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On October 13, 2021 at 8:53 AM, Licensing Program Analyst (LPA) Marilou Monico conducted an announced Prelicensing inspection. LPA met with Applicant, Paulina Pham, and explained the purpose of today's inspection.

9:00 AM - Application/Record Review: Applicant is the only adult residing in the home. The Applicant resides in a one-storey, three-bedroom and one and half-bathroom house. Days and hours of operation will be Monday to Friday from 8:00 AM to 5:00 PM. The Applicant's CPR and First Aid certification is current, with an expiration date of May 15, 2023 . Applicant's Mandated Reporter Training for Child Care Workers expires on September 21, 2023. The Applicant rents the home and Property Owner/Landlord Notification (LIC 9151), Property Owner/Landlord Consent (LIC 9149) as well as verification of control of property were submitted to Licensing. All individuals subject to a criminal record review have obtained a criminal record and child abuse index clearances prior to today's inspection.

9:15 AM - Physical Plant tour: There is a working telephone in the home (714) 260-6349. The home is clean and has heating and ventilation for safety and comfort. The off limit areas inside the home: kitchen, two bedrooms, storage (located in the playroom), office, and one bathroom. Off limit areas outside the home: side yard. There are safe and age appropriate toys, play equipment, and materials for the children in the home. The Applicant has a designated area in the home where a child(ren) can be isolated if exhibiting signs of illness. The home has working smoke/carbon monoxide detectors. The Applicant has two fire extinguishers (2A10BC) in the home that are fully charged. The Applicant states that she does not have any firearms in the home. All cleaning compounds, sharp objects, medications, and other similar items are stored inaccessible to the children. The Applicant understands that baby walkers, baby bouncers, jumpers, and saucer chairs are not allowed in the home. The Applicant states that no one in the home smokes and she understands that smoking is prohibited in the home. The Applicant has a first aid kit in the home. There were no bodies of water observed.

Continuation on next pages:
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2021
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: PHAM, PAULINA
FACILITY NUMBER: 434416736
VISIT DATE: 10/13/2021
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9:45 AM - Kitchen tour: The refrigerator and freezer in the home is clean. The kitchen area has a door to prevent the children from entering the kitchen. The Applicant understands that any food/drink which is brought by parent(s) of day care child(ren) must be properly labeled with the child(ren) name and properly stored or refrigerated.

9:50 AM - Bathroom tour: The toilet and faucet are clean, safe, and operable. Sharp objects and cleaning products are stored inaccessible to children.

9:55 AM - Document/Regulation Review: A Family Child Care Home packet with updated Licensing forms was provided to Applicant. Documents from the packet, including but not limited to the following were discussed and reviewed with the Applicant: 1) Child Care Facility Roster (LIC 9140) must be complete and current at all times, 2) Fire/disaster drills must be practiced at least once every 6 months and documented on the fire/disaster drill log provided to the Applicant, 3) Posting requirements - Parent's Rights (PUB 394), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), and Facility License, 4) Staffing & Ratio - capacity/ratio limitations handout, 5) Safe Sleep Regulations (PIN 20-24-CCP), 6) Lead Flyer Requirement (PIN 20-01-CCP), and 7) Forms and Records to keep in your Family Child Care Home (LIC 311D).

Applicant states that she will talk to the children and will use redirection as forms of discipline. The Applicant understands that children's personal rights should not be violated; including no corporal punishment, supervision of children, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed with the Applicant.

Incidental Medical Services (IMS) policy was discussed with the Applicant. 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 Applicant states that she does not plan on administering medication to the day care children at this time.
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SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
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: PHAM, PAULINA
FACILITY NUMBER: 434416736
VISIT DATE: 10/13/2021
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10:30 AM - Notification requirements/civil penalty: LPA discussed the requirements of AB 633 with the Applicant. The Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant 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. LPA advised Applicant 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.

Fire clearance was granted on September 24, 2021.

LPA conducted an exit interview and advised the Applicant that a license for a Large Family Child Care Home is approved effective today, October 13, 2021.
SUPERVISORS NAME: Anthony Studebaker
LICENSING EVALUATOR NAME: Marilou Monico
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021
LIC809 (FAS) - (06/04)
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