<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013421124
Report Date: 07/01/2022
Date Signed: 07/01/2022 03:44:12 PM

Document Has Been Signed on 07/01/2022 03:44 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:PHAN, HANGFACILITY NUMBER:
013421124
ADMINISTRATOR:PHAN, HANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 305-7483
CITY:NEWARKSTATE: CAZIP CODE:
94560
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
07/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:HANG PHANTIME COMPLETED:
04:00 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
On July 01, 2022 at approximately 11:50 AM, Licensing Program Analyst (LPA) Kelly Phan met with Licensee Hang Phan for an Unannounced Case Management visit to conduct a health and safety inspection. Present for today's visit are the licensee, licensee's fingerprinted and associated parents, her adult daughter, and her minor daughter who is 13 years old. There were also 13 children present (2 infants, 10 preschoolers, and 1 school aged child). Hours of operation is Monday to Friday from 7AM to 6PM.

At 12:10PM, LPA and licensee toured the ON limit areas that are the kitchen, eating area, hallway bathroom, play room, and living room. Per licensee, the backyard is still in construction and is not being used as a play area at the moment. All ON limit areas were found to be clean and safe for children in care, and does not have any hazardous items. The facility also dog. There is a fully charged 3A40BC fire extinguisher, working carbon monoxide, smoke detector, and telephone at the facility. Licensee has conducted and documented a fire drill on 06/04/22. All requiring licensing documents are posted for public review.

At 12:30PM, LPA also verified and checked on Guardian that her adult daughter is not associated to her facility as she had just turned 18 years old on February. LPA informed licensee to complete her adult daughter's fingerprints and as of today, LPA will have to assess a civil penalty of $500.00 as her daughter has resided at her home without an eligible clearance; Licensee states that she has completed and submitted but does not show in the system. SEE LIC 809 D. At 1:00PM, 6 children files were reviewed with licensee and found to be complete along with her facility file; Licensee has mandated reporter training completed on 03/15/2021; both licensee, her helper, and adult daughter has CPR and First aid training completed as of 06/12/2021.

SEE LIC 809 C


SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: PHAN, HANG
FACILITY NUMBER: 013421124
VISIT DATE: 07/01/2022
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
26
27
28
29
30
31
32
There are two deficiencies cited during today's visit: 1 Type A - LPA verified and review Guardian that the licensee's adult daughter does not have eligible clearance

1 Type B - Licensee failed to report incident to licensing within 24hrs and submit a LIC 624B (Unusual Incident report) within 7 business days; Licensee states that she was not aware of reporting it within 24hrs and is interviewing with families for more details on her unusual incident report to Licensing.

LPA Kelly PHAN informed licensee Phan that this report dated 07/01/2022 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Kelly PHAN informed the licensee to provide a copy of this licensing report dated 07/01/2022 that documents any Type A citation(s) 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), or other written statement, must be placed in the child's file for verification.


Appeal rights and a notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.00. Exit interview conducted and report was reviewed with licensee Hang Phan
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Kelly Phan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/01/2022 03:44 PM - It Cannot Be Edited


Created By: Kelly Phan On 07/01/2022 at 03:18 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PHAN, HANG
FACILITY NUMBER: 013421124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2022
Section Cited
CCR
102416(d)(1)

1
2
3
4
5
6
7
Personnel Requirements: 102416 (d)(1): Prior to employment or initial presence in the child care home, all employees and volunteers subject to a criminal record review shall: Obtain a California clearance or a criminal record exemption as required by law or Department regulations
This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee states that she would immediately get her daughter's fingerprints done later today, 07/01/2022.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the section cited above as licensee failed to obtain a criminal clearance for her adult daughter who has resides at her facility, which poses an immediate health, safety or personal rights risk to persons in care
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jason Jang
LICENSING EVALUATOR NAME:Kelly Phan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/01/2022 03:44 PM - It Cannot Be Edited


Created By: Kelly Phan On 07/01/2022 at 03:24 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: PHAN, HANG
FACILITY NUMBER: 013421124

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
07/01/2022
Section Cited
CCR
102416.2(3)(C)

1
2
3
4
5
6
7
Reporting Requirements: 102416.2(3)(B): Health and Safety Code Section 1597.467(b)(1) provides in part: "A report shall be made to the Department…following the occurrence during the operation of a family day care home of any of the following events: Any unusual incident or child absence that threatens the physical or emotional health or safety of any child."
This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Licensee would submit an unusual incident to Licensing within next week.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the section cited above as licensee failed to report an unusual incident to Licensing, which poses an immediate health, safety or personal rights risk to persons in care
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Jason Jang
LICENSING EVALUATOR NAME:Kelly Phan
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4