434416496-12-15-2021-07-CC-JCRZ-C9QUPY-20211215144619

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416496
Report Date: 12/15/2021
Date Signed: 12/15/2021 02:46:30 PM

Document Has Been Signed on 12/15/2021 02:46 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:	PHAN, NGAN		FACILITY NUMBER:	434416496
ADMINISTRATOR:	NGAN PHAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(669) 226-0398
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95111
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 1	DATE:	12/15/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Ngan, Phan		TIME COMPLETED:	03:00 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	Licensing Program Analysts (LPAs) Janette Cruz and Mel Matos conducted an announced pre licensing inspection with Ngan Phan, Applicant. The purpose of today's inspection: address the Application for a new Large Family Child Care Home license that the Applicant submitted to the Department on Sep. 03, 2021. Application/Record Review: Applicant and her minor daughter (1 year of age) were present in the home during today's inspection. The Applicant states that she is the only adult residing in the home. Applicant also has 3 minor children: (son – age 9 and daughters ages 1 year and 8 months) residing in the home. Days and hours of operation will be Monday to Friday from 8:00 AM to 6:00 PM. Applicant completed the Preventative Health and Safety Training with Lead Training on 11/14/2021 and a copy of the certification is on file. Applicant has proof of Pediatric CPR and First Aid training with expiration date of 09/28/2023 on file. Applicant has updated vaccinations (including flu vaccine) and proof of completion of the Mandated Reporter Training for Child Care Workers completed on 09/23/2021 on file. The Applicant rents the home and a copy of the lease agreement verifying control of property is on file. The completed Property Owner/Landlord Notification (LIC 9151) form is on file. Applicant states that she intends to have up to 14 children in her day care. All individuals subject to a criminal record review (Applicant) have obtained a criminal record and child abuse index clearances prior to today's inspection. Note: this is subject to further review to confirm whether other adult/s are residing on the property. The Applicant agreed to give LPAs a tour of the home during today’s inspection. Physical Plant Tour : Per facility sketch, the Applicant's home is a single story home with four bedrooms, one bathroom, living room, kitchen, dining area, attached garage, and backyard. LPAs observed that the three bedrooms were locked and inaccessible during inspection. There is a working telephone in the home (cell #669-226-0398).

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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: PHAN, NGAN	FACILITY NUMBER: 434416496
	VISIT DATE: 12/15/2021

NARRATIVE

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LPAs observed the home is clean and orderly. There is no fireplace and no central A/C unit inside the home. There is a double wall heater unit located between the living room and hallway bathroom entrance that is not barricaded. The off-limit areas inside the home are: 4 bedrooms and attached garage. Off-limit areas outside the home - left side of the back yard. There are safe and age appropriate toys, play equipment, and materials for the children in the home.

LPAs observed that the Applicant has designated the dining area where child(ren) can be isolated if exhibiting signs of illness. The home has working smoke and carbon monoxide detectors in the home. Applicant has one fully charged fire extinguisher (3A40BC) inside the home. Applicant states that there are no pets, firearms or weapons in the home. LPAs observed cleaning compounds and medications are not adequately stored and accessible to children at this time. Applicant was reminded that any poison inside the home must be kept locked. Applicant states that she does not have any baby walkers in the home. Applicant understands that baby walkers are not allowed in the day care. Applicant understands that high chairs are to be used only for eating purposes. Applicant states that no adult smokes and she understands that smoking is prohibited in the home.

Kitchen tour: LPAs observed the refrigerator and freezer in the home are clean. There are no sharp utensils, cleaning products, lighters/matches, or open bottles of alcohol accessible to children. 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.

Bathroom tour: LPAs observed the bathroom toilet and faucet are clean, safe, and operable. Not all cleaning products were inaccessible to the children during today's inspection.

Outdoor tour: LPAs observed the outdoor backyard area of the home is fenced and secure for the children. LPAs observed wood debris, tools, an old oven, and paint buckets that are accessible to children on the right side section of the backyard. LPAs also observed an old television, and additional debris on the front yard area that needs to be removed. There are no bodies of water on the property.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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: PHAN, NGAN	FACILITY NUMBER: 434416496
	VISIT DATE: 12/15/2021

NARRATIVE

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Document/Regulation Review: LPAs provided a Family Child Care Home packet with updated Licensing forms to the Applicant during today's inspection. Documents from the packet were discussed and reviewed with the Applicant. COVID-19 required postings/resource/self-assessment information were also provided to the Applicant. COVID-19 self-assessment also completed during today's tele-inspection.

Applicant stated that forms of discipline that will be used is "talking and redirecting children." The Applicant understands that children's personal rights should not be violated. The requirements for assistant/substitute were also discussed with the Applicant during today's inspection.

Incidental Medical Services (IMS) policy was discussed with the Applicant during today's tele-inspection. 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.

Notification requirements: LPAs 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).

LPAs conducted an exit interview and advised the Applicant that a large Family Child Care Home license will be approved upon completion of the following:

1. Cleaning compounds and medications in the home are adequately stored and inaccessible
2. Fire clearance approval received from the San Jose Fire Department
3. Double wall heater has been barricaded
4. LPAs are granted access to the three bedrooms inside that the home that are currently locked and inaccessible
5. Updated indoor sketch submitted to LPA Cruz. Must include attached garage as off-limits area of the home

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

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: PHAN, NGAN	FACILITY NUMBER: 434416496
	VISIT DATE: 12/15/2021

NARRATIVE

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5. Right side of backyard section and front yard areas have been cleaned-up.
6. Natural gas pipe located alongside the exterior of the home and middle fence area at the right side of backyard needs to be barricaded
7. Applicant's verification of residency - (ex. proof of mail service, including utilities).
8. Verification if additional adult/s are residing in the home.
9. Case and application to be reviewed by LPAs manager.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Janette Cruz
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021

LIC809 (FAS) - (06/04)

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