434416542-4-26-2023-07-CC-MSMS-CR9NY5-20230426105212

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434416542
Report Date: 04/26/2023
Date Signed: 04/26/2023 10:52:21 AM

Document Has Been Signed on 04/26/2023 10:52 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, NGAN		FACILITY NUMBER:	434416542
ADMINISTRATOR:	NGAN PHAN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 690-9099
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95121
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	04/26/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Ngan Phan		TIME COMPLETED:	11:15 AM

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) Mel Matos & Farida Raja met with Applicant, Ngan Phan, to conduct an announced prelicensing inspection at 3894 Glengrove Way, San Jose, CA 95121. LPAs were granted access to the home by the Applicant. Applicant's two minor children, ages 3 & 2 years ,and two adult renters (Tracy Trieu and Minh Nguyen) were present during today's inspection. The Applicant and three renters (Minh Nguyen, Tracy Trieu, & Thu Nguyen) are the adults residing in the home. Applicant has three minor children of her own (ages 10, 3, & 2 years) and Thu Nguyen has one 12 year old child residing in the home. Days and hours of operation will be Monday - Friday from 8:00 AM to 6:00 PM. 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 09/28/2023. The Applicant completed the Mandated Reporter Training for Child Care Workers on 09/23/2023 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. The Property Owner/Landlord Notification (LIC 9151) and Property Owner/Landlord Consent (LIC 9149) forms are 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) to all enrolling families. LPAs toured the indoor and outdoor areas of the home with the Applicant during today's inspection. There are no stairs or wall heater units inside the home. Per the approved fire safety inspection (STD 850) dated 02/24/2023 from San Jose Fire Department, the areas to be used for the day care shall be the living room, dining room, family room, and backyard. Off limit areas inside the home: master bedroom, master bathroom, barricaded fireplace (located in the family room), and attached garage. Note: Per LPAs observations, statement from Applicant, and Applicant's landlord(Thanh-Tung Nguyen), the attached garage is currently being converted to an JADU unit. LPAs observed construction workers on site during today's inspection and obtained a copy of the construction permit. Off limit area outside the home: entire backyard (during construction process). The home is clean, orderly, including heating and ventilation, for safety & comfort. The 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. LPAs observed a fully charged fire extinguisher (2A10BC), working smoke and carbon monoxide detectors, no bodies of water, and fenced backyard. Applicant states that she does not have any weapons/ammunition or pets in the home.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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: 04/26/2023

NARRATIVE

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Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. Applicant states that there are no poisons in the home. LPAs reminded Applicant that smoking, baby walkers, and similar items are not allowed in Family Child Care Homes. Applicant states that she will not administer any medication to the children at this time. Applicant states that a child will be isolated in the living room area if necessary due to illness or communicable disease. Applicant has a First Aid kit with a touchless thermometer in the home.

Forms of discipline to be used by Applicant: time-out. Applicant understands that children's personal rights should not be violated; including no corporal punishment. isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPAs informed the Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

Ngan Phan, Applicant, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPAs discussed the requirements of AB 633 with the Applicant. Applicant understand the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPAs provided and reviewed the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPAs provided and discussed the safe sleep regulations with the Applicant 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. LPAs also informed the Applicant 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

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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: 04/26/2023

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APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
Incidental Medical Services (IMS) policy was discussed. 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: http://www.ada.gov/childqanda.htm

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Applicant, Ngan Phan, and LPAs advised her that the following must be completed prior to a large Family Child Care Home license being approved:

1) JADU unit construction must be completed and final permit approval received from the city of San Jose.
2) Revised Facility sketches (LIC 999) for the indoor and outdoor areas of the home must be submitted. All off limit areas must be noted on the sketches.
3) Revised fire clearance from the city of San Jose has been received.
4) Follow up inspection has been completed by the Department.
5) Management review and approval.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

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