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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416542
Report Date: 03/29/2023
Date Signed: 03/29/2023 11:09:22 AM

Document Has Been Signed on 03/29/2023 11:09 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:PHAN, NGANFACILITY NUMBER:
434416542
ADMINISTRATOR:NGAN PHANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 690-9099
CITY:SAN JOSESTATE: CAZIP CODE:
95121
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
03/29/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Ngan PhanTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Mel Matos met with Applicant, Ngan Phan, to conduct an announced prelicensing inspection at 3894 Glengrove Way, San Jose, CA 95121. LPA was granted access to the home by the Applicant. Two adult renters, Tracy Trieu & Minh Nguyen, and two of Applicant's children, ages 2 & 3 years, were present during today's inspection. The Applicant and three adult renters (Minh Nguyen, Thu Nguyen, Tracy Trieu) are the adults residing in the home. Applicant has three minor children (ages 10, 3, and 2 years) and Thu Nguyen, adult renter, has one minor child (age 11 years) residing in the home.

Days and hours of operation will be Monday - Friday from 8AM - 6 PM. The Applicant completed her Preventative Health and Safety Child Care Training on 11/14/2021 and a copy of the certification is on file. The Applicant's CPR and First Aid certifications are current and expire on 09/28/2021. The Applicant has completed the Mandated Reporter Training for Child Care Workers on 09/23/2021 and a copy of the certification is on file. A copy of current TB test, flu (opt out), MMR, and Tdap vaccinations for the Applicant is on file. Applicant rents the home and a copy of the lease agreement verifying control of property is on file. Applicant does not have liability insurance at this time and will issue Affidavit Regarding Liability Insurance for Family Child Care Home (LIC 282) until she obtains insurance coverage.

LPA toured the indoor and outdoor areas of the home with the Applicant during today's inspection. There are not any stairs or wall heater units inside the home. Off limit areas inside the home: barricaded fireplace in the living room area, two bedrooms, one master bedroom, one master bathroom, and attached garage. Off limit area outside the home: left, right, and back sides of the backyard.

The home is clean, orderly, (including heating/air conditioning), and ventilation for safety & comfort. Applicant has a valid phone in the home (408-690-9099). There is sufficient toys, supplies, and equipment for the day care children both indoors/outdoors. LPA observed a fully charged fire extinguisher (2A10BC), working smoke and carbon monoxide detectors, no bodies of water, and fenced front yard. Applicant states that she does not have any pets or weapons in the home.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/29/2023
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: 434416542
VISIT DATE: 03/29/2023
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The home is clean, orderly, (including heating/air conditioning), and ventilation for safety & comfort. Applicant has a valid phone in the home (408-690-9099). There is sufficient toys, supplies, and equipment for the day care children both indoors/outdoors. LPA observed a fully charged fire extinguisher (2A10BC), working smoke and carbon monoxide detectors, no bodies of water, and fenced front yard. Applicant states that he does not have any pets or weapons in the home.

Applicant showed LPA a copy of her water bill, electric/gas bill, and wi-fi bill during today's inspection. LPA also interviewed two adult renters (Tracy Trieu and Minh Nguyen) during today's inspection. LPA notes that he also toured Tracy's and Minh's bedrooms during today's inspection.



LPA advised the Applicant that her file will be reviewed with Community Care Licensing management and legal department to further discuss her application and verification of residency status in the home. Applicant will be contacted if additional documentation is required.

LPA advised the Applicant that she can "withdraw" her application by submitting a written/signed letter to LPA Matos if she elects not to pursue the licensing process.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:

DATE: 03/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2023
LIC809 (FAS) - (06/04)
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