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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
434417391
Report Date:
01/15/2025
Date Signed:
01/16/2025 08:30:21 AM
Document Has Been Signed on
01/16/2025 08:30 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:
PHAN, NGAN
FACILITY NUMBER:
434417391
ADMINISTRATOR/
DIRECTOR:
PHAN, NGAN
FACILITY TYPE:
810
ADDRESS:
TELEPHONE:
(408) 690-9099
CITY:
SAN JOSE
STATE:
CA
ZIP CODE:
95121
CAPACITY:
14
TOTAL ENROLLED CHILDREN:
14
CENSUS:
12
DATE:
01/15/2025
TYPE OF VISIT:
Annual/Random
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:
Ngan Phan
TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 01/15/2024 at 8:47am, Licensing Program Analyst (LPA), Farida Raja, conducted an unannounced annual/random inspection. LPA was granted access to the home by Assistant, Hang Huynh and explained the nature of today’s inspection. Licensee was not home and Assistant stated that she is out dropping her child to school. Licensee arrived at 9:06am. Upon arrival, LPA observed 1 staff and 5 preschool children. Children continued to arrive during today's inspection. Facility was operating within the ratio and capacity requirements of the license. Days and hours of operation are Monday to Friday, 8:00 am to 6:00 pm. LPA observed the facility license but did not observe the other required postings near the facility entrance. LPA provided Licensee with the LIC 126 (Entrance Checklist for Family Child Care Homes) stating the required postings and informed Licensee to have postings near the front entrance so they are visible to parents/ authorized representatives. Licensee and two adults (Thu Nguyen, Minh Nguyen) reside in the home and three adults (Thi To, Hau Nguyen and Dat To) reside in the JADU. Licensee has four minor children residing in the home.
Licensee to submit an updated Application for Family Child Care Home License (LIC 279) to LPA by 01/29/2025.
LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. LPA observed toys scattered in the family room which can be a tripping hazard. LPA observed a basket in the living room that is broken and has sharp edges. LPA observed a baby bouncer in the on limit area near the children's cubbies. LPA reminded Licensee that baby walkers, bouncers and similar items are not allowed in family child care homes. Licensee placed the bouncer in an off limit area during today's inspection. Furniture and cots are in good condition. The home has central heating, wall mounted air conditioning unit and ventilation for comfort of children. LPA observed a fireplace with a glass cover in the on limit family room. LPA observed that the glass cover did not close tightly and the fireplace could be accessed by children. Off limit areas inside the home master bedroom, master bathroom, two bedrooms, kitchen and entire JADU.
Continued on Page 2
SUPERVISORS NAME
:
Gladys Kuizon
LICENSING EVALUATOR NAME
:
Farida Raja
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/15/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
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
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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-DAY CARE
,
2580 N FIRST STREET, STE. 300
SAN JOSE
,
CA
95131
FACILITY NAME:
PHAN, NGAN
FACILITY NUMBER:
434417391
VISIT DATE:
01/15/2025
NARRATIVE
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Backyard is fenced and gated. Off limits area outdoors: left, right, and back portions of the backyard and fenced laundry area. Applicant understands that children must be supervised at all times while outdoors. There are no bodies of water observed. LPA observed toys and play materials scattered around the outside play area and spider webs on the wooden awning. Play equipment was observed to be age appropriate but some items were in disrepair. Licensee stated that children are not taken outdoors at present due to the cold weather. LPA reminded Licensee to maintain a clean and safe environment for children, inspect children's items regularly and make inaccessible items that are broken or in disrepair. LPA observed that the bathroom used by children was in operating condition. Toilets and faucet are clean and operable. Toothpaste, air fresheners and cleaning products were observed under the bathroom sink that are accessible to children. LPA observed soaps and shampoos in the shower stall that are within reach of children. LPA reminded Licensee that toothpaste, shampoos, air fresheners, razors, mouthwash, perfumes and similar items need to be placed inaccessible to children in care.
During facility walk through LPA observed cabinet under the kitchen sink is broken and soaps and poisons (Raid roach killer spray) are accessible to children. LPA observed children playing in the kitchen area and accessing the cabinet under the sink during today's visit. LPA reminded Licensee that poisons, cleaning products and detergents that pose a danger if readily available need to be locked and stored inaccessible to children in care.
A fully charged 2A10BC fire extinguisher and carbon monoxide detector was observed. LPA reminded licensee that the fire extinguisher needs to be serviced once every 12 months. LPA did not observe any smoke detectors in the on limit areas. Licensee stated that she removed them and has not replaced them yet. Licensee states that she does not have any weapons or pets in the home. Licensee understands that smoking is prohibited in the home.
Drinking water was observed to be readily available for children in the home via individual water bottles. Licensee stated that she provides lunch and snacks to the children in care.
LPA observed milk bottles provided for children by parents were stored in the refrigerator but were not labeled with their names.
LPA reminded Licensee that any food brought from home including milk needs be labeled with each child's name and properly stored or refrigerated. Licensee states that a child will be isolated in the family room due to illness or communicable disease.
Continued on Page 3
SUPERVISORS NAME
:
Gladys Kuizon
LICENSING EVALUATOR NAME
:
Farida Raja
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
2
of
13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
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:
PHAN, NGAN
FACILITY NUMBER:
434417391
VISIT DATE:
01/15/2025
NARRATIVE
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Licensee has not maintained a current facility roster and and not conducted and maintained a log of fire/disaster drills. A random selection of 9 children's (3 infants and 6 preschool age) files were reviewed during today's inspection. Licensee has not conducted and documented 15 minute checks for 3 infants (C1, C2 and C9) in care. Children, C3 and C9 are missing immunization records, C2 and C3 are missing LIC 627 (Consent for Emergency Medical Treatment) and C1, C2 and C9 are missing LIC 995A (Notification of Parents Rights). Licensee does not have liability insurance for the day care and thus issues the Affidavit Regarding Liability Insurance for Family Child Care Home to all families.
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 provided licensee with a copy of an Individual Infant Sleeping Plan (LIC 9227) for infants 12 months and under and a sample 15- minute sleeping infant check form for children under 2 years of age.
LPA reviewed Licensee and assistant's files for the required forms. A review of staff records indicated that Assistant (S2) does not have criminal records and child abuse index clearances. 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.
Licensee and assistant have the required immunization in file for measles, pertussis and statement declining influenza and are current with Mandated Reporter Training for Child Care Workers. Licensee and assistant have current pediatric CPR/First Aid certifications.
Continued on Page 4
SUPERVISORS NAME
:
Gladys Kuizon
LICENSING EVALUATOR NAME
:
Farida Raja
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
3
of
13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
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:
PHAN, NGAN
FACILITY NUMBER:
434417391
VISIT DATE:
01/15/2025
NARRATIVE
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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. LPA discussed the requirement for Licensee to be present at the facility 80 percent of the hours the facility is in operation and that temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day. 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.
Licensee is encouraged to visit the Department’s website at
https://cdss.ca.gov/inforesources/child-care-licensing
to access general updates, resources for providers, regulations, adoptions of new laws, pay annual fees etc. The Department will communicate all new information to providers through Provider Information Notices (PINs). Please sign up to be notified for new PINs at
www.cdss.ca.gov/inforesources/community-care-licensing/subscribe
and visit the Department’s website for the latest PINs.
Incidental Medical Services (IMS) policy was discussed. Licensee stated that she is not providing any medications 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. 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. LPA reminded Licensee that if she decides to transport children, children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.
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.
Continued on Page 5
SUPERVISORS NAME
:
Gladys Kuizon
LICENSING EVALUATOR NAME
:
Farida Raja
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
4
of
13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
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:
PHAN, NGAN
FACILITY NUMBER:
434417391
VISIT DATE:
01/15/2025
NARRATIVE
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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.
Three Type A, nine Type B deficiencies and one technical violation were cited as a result of today's inspection. One civil penalty was issued.
LPA Raja informed licensee, Ngan Phan that this report dated 01/15/2024 documents 3 Type A citations which shall be posted for 30 consecutive days as there are immediate risks 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 01/15/2025 that documents Type A citations 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) must be placed in the child's file for verification. Appeal rights and LIC 9224 were printed and provided to Licensee.
Exit interview conducted and report was reviewed with Licensee, Ngan Phan.
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
.
SUPERVISORS NAME
:
Gladys Kuizon
LICENSING EVALUATOR NAME
:
Farida Raja
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
5
of
13
Document Has Been Signed on
01/16/2025 08:30 AM
- It Cannot Be Edited
Created By:
Farida Raja
On
01/15/2025
at
12:23 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:
PHAN, NGAN
FACILITY NUMBER:
434417391
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance (d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above for one staff (S2) which poses an immediate health, safety or personal rights risk to persons in care. Staff has been working at this facility since December 2024 without fingerprint clearance.
POC Due Date:
01/16/2025
Plan of Correction
1
2
3
4
Licensee to obtain fingerprint clearance for S2 and submit a plan of correction to LPA by 01/16/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
01/15/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
6
of
13
Document Has Been Signed on
01/16/2025 08:30 AM
- It Cannot Be Edited
Created By:
Farida Raja
On
01/15/2025
at
12:30 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:
PHAN, NGAN
FACILITY NUMBER:
434417391
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(4)
Operation of A Family Child Care Home
(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
1
2
3
4
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. LPA observed cabinet under the kitchen sink is broken and soaps and poisons (Raid roach killer spray) are accessible to children. LPA observed children playing in the kitchen area and accessing the cabinet under the sink during today's visit. LPA observed toothpaste, air fresheners and cleaning products under the bathroom sink and shampoos in the shower stall within reach of children.
POC Due Date:
01/16/2025
Plan of Correction
1
2
3
4
Licensee to make above stated items inaccessible to children and submit picture proof and written statement to LPA by 01/16/2025.
Type A
Section Cited
CCR
102417(g)(10)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (10) A baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety Code Sections 1596.846(b) and (c).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
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. LPA observed a baby bouncer in the on limit area near the children's cubbies. LPA reminded Licensee that baby walkers, bouncers and similar items are not allowed in family child care homes.
POC Due Date:
01/16/2025
Plan of Correction
1
2
3
4
Licensee to submit a plan of correction to LPA by 01/16/2025.
Licensee placed the bouncer in an off limit area during today's inspection.
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:
01/15/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
7
of
13
Document Has Been Signed on
01/16/2025 08:30 AM
- It Cannot Be Edited
Created By:
Farida Raja
On
01/15/2025
at
12:30 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:
PHAN, NGAN
FACILITY NUMBER:
434417391
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(f)
Operation of A Family Child Care Home
(f) If food is brought from the children's homes, the container shall be labeled with the child's name and properly stored or refrigerated.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that the milk bottles provided for children by parents were stored in the refrigerator and were not labeled with their names.
POC Due Date:
01/29/2025
Plan of Correction
1
2
3
4
Licensee to submit a written plan of correction to LPA by 01/29/2025.
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. LPA observed that the glass cover on the fireplace did not close tightly and the fireplace could be accessed by children. LPA did not observe any smoke detectors in the on limit areas. Licensee stated that she removed them and has not replaced them yet.
POC Due Date:
01/29/2025
Plan of Correction
1
2
3
4
Licensee to secure glass cover or additionally barricade fireplace so as to make if off limits to children. Licensee to replace smoke detectors and submit proof of working smoke detectors. Licensee to submit picture/video proof along with written statement to LPA by 01/29/2025.
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:
01/15/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
8
of
13
Document Has Been Signed on
01/16/2025 08:30 AM
- It Cannot Be Edited
Created By:
Farida Raja
On
01/15/2025
at
12:30 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:
PHAN, NGAN
FACILITY NUMBER:
434417391
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee has not conducted and maintained a log of fire/disaster drills.
POC Due Date:
01/29/2025
Plan of Correction
1
2
3
4
Licensee to conduct fire/disaster drill and submit proof to LPA by 01/29/2025.
Type B
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited which poses a potential health, safety or personal rights risk to persons in care. LPA observed the facility license but did not observe the other required postings near the facility entrance.
POC Due Date:
01/29/2025
Plan of Correction
1
2
3
4
Licensee to submit a plan of correction to LPA including picture proof of required postings by 01/29/2025.
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:
01/15/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
9
of
13
Document Has Been Signed on
01/16/2025 08:30 AM
- It Cannot Be Edited
Created By:
Farida Raja
On
01/15/2025
at
12:30 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:
PHAN, NGAN
FACILITY NUMBER:
434417391
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above for two children, C3 and C9 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/29/2025
Plan of Correction
1
2
3
4
Licensee to obtain immunization records and submit proof to LPA by 01/29/2025.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above for two children, C2 and C3 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/29/2025
Plan of Correction
1
2
3
4
Licensee to obtain missing LIC 627 for two children and submit proof to LPA by 01/29/2025.
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:
01/15/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
10
of
13
Document Has Been Signed on
01/16/2025 08:30 AM
- It Cannot Be Edited
Created By:
Farida Raja
On
01/15/2025
at
12:30 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:
PHAN, NGAN
FACILITY NUMBER:
434417391
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Licensee has not maintained a current facility roster.
POC Due Date:
01/29/2025
Plan of Correction
1
2
3
4
Licensee to complete a current roster and submit proof to LPA by 01/29/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
01/15/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
11
of
13
Document Has Been Signed on
01/16/2025 08:30 AM
- It Cannot Be Edited
Created By:
Farida Raja
On
01/15/2025
at
12:30 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:
PHAN, NGAN
FACILITY NUMBER:
434417391
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above for three children, C1, C2 and C9 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/29/2025
Plan of Correction
1
2
3
4
Licensee to have parents complete the missing LIC 995A for three children and submit proof to LPA by 01/29/2025.
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:
01/15/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
12
of
13
Document Has Been Signed on
01/16/2025 08:30 AM
- It Cannot Be Edited
Created By:
Farida Raja
On
01/15/2025
at
12:30 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:
PHAN, NGAN
FACILITY NUMBER:
434417391
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/15/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above for three infants (C1, C2 and C9) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
01/29/2025
Plan of Correction
1
2
3
4
Licensee to conduct and maintain log of 15 minute nap check for all infants and submit proof to LPA by 01/29/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
01/15/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/15/2025
LIC809
(FAS) - (06/04)
Page:
13
of
13