Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304300901
Report Date: 03/06/2019
Date Signed: 03/06/2019 12:39:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:TRAN-BELLEVILLE, PATRICIAFACILITY NUMBER:
304300901
ADMINISTRATOR:TRAN-BELLEVILLE, PATRICIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 891-6918
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:14CENSUS: 10DATE:
03/06/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Licensee Patricia Tran-BellevilleTIME COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Ho and Quinto met with licensee and toured the facility inside and outside. LPA observed 2 infants and 8 preschoolers playing in the living room. The facility was within licensed capacity and the required ratio. Also, present during the visit was licensee's assistant. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. This is a single story home with three bedrooms and 2 baths. Licensee stated off limit areas include: the kitchen. Licensee acknowledged that children may never enter these off-limit areas. Family members residing at facility are 2 adults and no children. The home was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, and hazardous items that can pose a danger to children.

Per Licensee there are no weapons, firearms in the facility at this time. Anytime when firearms were present in the facility, they must be locked and inaccessible to children. The ammunition must be locked and separate from the firearms. No *swimming pool, spa or other bodies of water observed on the premises. There are age appropriate toys and equipment on the premises. The required fire extinguisher (2A10BC), carbon monoxide, and smoke detectors are in operable condition. Facility roster, disaster drill, staff members' required immunization (MMR, TDAP, FLU), and mandated reporter training certificates were available for review. The licensee was reminded that must present at facility and ensure that children are properly cared for and supervised at all times. The licensee must make sure that a substitute adult cares for the children when licensee is temporarily absent. The licensee was also reminded that no child shall be left alone in a parked vehicle at any time. All day-care activities take place in the living room and all 3 bedrooms. Children are able to have outside play in the enclosed backyard. Licensee and assistants are current with Pediatric CPR and First Aid and both valid until 7/2020

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: TRAN-BELLEVILLE, PATRICIA
FACILITY NUMBER: 304300901
VISIT DATE: 03/06/2019
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equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to presence in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. No smoking, no infant walkers, No Johnny jumpers, no exersaucer or any other similar items that fall into that category are allowed in the facility. Disaster drills, posting requirements, children records, mandated child abuse and injury/ death reporting, and criminal records clearances/exemption transfer requests, SIDS and Never Shake a Baby.



After a tour of the home and review children and staff's records, no deficiency was observed.

During exit interview, “The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.” Notice of Site Visit was posted. Licensee was informed to keep the Notice of Site Visit posted for 30 days during the daycare hours or $100 civil penalty will be assessed.

The facility representative was informed that the CRIMINAL RECORD STATEMENT (LIC 508) has been updated, and the facility must now use the new form with revised date 7/15. The facility representative was also informed that the LIC 508 must be submitted with all Criminal Background Clearance Transfer Request (LIC9182). The facility representative was informed that Licensing Updates are available at www.ccld.ca.gov

Information on the additional nutrition training, immunization requirements for children, and Health Schools Act (http://www.cdpr.ca.gov/docs/pestmgt/schoolipm.htm) were provided. The facility representative was
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: TRAN-BELLEVILLE, PATRICIA
FACILITY NUMBER: 304300901
VISIT DATE: 03/06/2019
NARRATIVE
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informed, and website given, about the California Child Care Disaster Plan has been posted to the UCSF California Childcare Health Program website: cchp.ucsf.edu/content/disaster-preparedness Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org and a copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided.

LPA reviewed with licensee the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt
and not be too hot or too cold.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2019
LIC809 (FAS) - (06/04)
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