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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700220
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:11:48 PM

Document Has Been Signed on 02/02/2023 03:11 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:CHHON, NARYFACILITY NUMBER:
015700220
ADMINISTRATOR:CHHON, NARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 815-9346
CITY:DUBLINSTATE: CAZIP CODE:
94568
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Licensee, Chhon Nary TIME COMPLETED:
03:30 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 Analyst (LPA) Jyoti Saini met with Licensee Nary Chhon for an unannounced Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during this inspection was Licensee and her husband supervising one infant and 11 preschoolers. Licensee is within capacity limits of a Large License. The home is a two-story home with 4 bedrooms, 3 bathrooms, large open entry way, den, living room, kitchen, dining room, laundry room, garage, and back yard. Licensee lives in this house with her husband. The hours of operation are 8:30AM- 5:30PM, Monday -Friday.
On-limit-areas are: are the large open entry way, dining room, kitchen, living room and den(playroom/naproom)
Off limit area: are the entire second floor which consist of 4 bedrooms, 2 bathrooms, laundry room and garage. All the off-limit areas are made inaccessible to children by locked doors, safety gates and visual supervision
LPA observed the following: Daycare Area is clean, orderly, and equipped with age appropriate toys and equipment for children, indoors and outdoors. Home has a working telephone, a working smoke and carbon monoxide detector, and a fire extinguisher that meets the minimum requirements. There are no bodies of water. There is Fireplace in the Daycare area which is not in use. There are child size tables and chairs for snack and activities. There are ample of age appropriate toys that appear to be safe and in good condition. LPA did not observe any hazardous materials or toxins accessible to children during today’s inspection. The napping room had cots in good condition and each child have their separate blankets. The blankets are washed weekly by the Parents. There is a child safety gate located at the bottom of the stairs to prevent access to the stairs and upper levels to children in care. The outdoor play area is fenced. Licensee states there are no guns or weapons of any kind in the home. Licensee's husband's CPR expire in 09/30/2024. Licensee has current Mandated reporter training on the file. Licensee conducted last emergency drill on 01/24/2022. Licensee provides daily snacks and meals. Discipline policy is redirection. LPA reviewed children’s files. All the files are complete and up to date. All required postings are properly posted.

See next page..

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE: DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/02/2023
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 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: CHHON, NARY
FACILITY NUMBER: 015700220
VISIT DATE: 02/02/2023
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
During Inspection, Licensee was reminded that all adults 18 and over living or working in the home, 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.

LPA discussed the safe sleep regulations with licensee 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. LPA also informed licensee 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.



Licensee was reminded about Mandated Reporter training available on CCLD website. Training must be completed every 2 years. Training can be taken online at www.mandatedreporterca.com

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

A notice of site visit was given and must remain posted for 30 days.

The attached type B deficiencies are cited today.

Exit interview conducted and report was reviewed with the licensee, Nary Chhon.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Jyoti Saini
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/02/2023 03:11 PM - It Cannot Be Edited


Created By: Jyoti Saini On 02/02/2023 at 01:27 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: CHHON, NARY
FACILITY NUMBER: 015700220

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation,interview, and record review, the licensee did not comply with the section cited above. The review of drill log indicates that the last drill was conducted 01/24/2022. This poses a potential health and safety risk to children in care.
POC Due Date: 02/06/2023
Plan of Correction
1
2
3
4
 Licensee shall submit proof of correction by the aforementioned date. Failure to follow through with this plan of correction will result in a civil penalty of $100 per day until corrected.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with this requirement as there was no file for C10 and C11, which poses a potential Health and Safety risk to children in care.
POC Due Date: 02/06/2023
Plan of Correction
1
2
3
4
Licensee shall obtain the missing forms by 2/06/2023 and mail a copy to Licensing as proof of correction.
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:Wynn Norona
LICENSING EVALUATOR NAME:Jyoti Saini
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3