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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010145
Report Date: 05/20/2022
Date Signed: 05/20/2022 02:31:24 PM

Document Has Been Signed on 05/20/2022 02:31 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:NGUYEN, HOANG FCCHFACILITY NUMBER:
493010145
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
05/20/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Hoang "Kim" NguyenTIME COMPLETED:
02:40 PM
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A prelicensing inspection was conducted today by Licensing Program Analysts Sebastian Phouthavong and Jennifer Velasco (LPA). Applicant Hoang “Kim” Nguyen (L1) is requesting a license for a capacity of eight children. Services will be available Monday through Friday, 7:00 a.m. – 6:00 p.m. L1 understands 24-hour consecutive care is prohibited. There are two adults living in the home. L1 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. The floor and yard plans are verified. Care will be provided in the living room, hall bathroom, and backyard. The off-limits areas of the home include, the entire 2nd floor of the home, the stairs, laundry room, kitchen, utility closets, one section of the backyard, one side yard, backyard shed, and the garage, made inaccessible by means of door knob covers, gates, fencing, key/combination locks, and/or door locks. The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone. The sharp knives, cleaning supplies, and medicines are stored out of the reach of children. L1 stated there are no guns or dangerous weapons in the home, and none were observed. Any poisons will be stored in the shed which has a keyed lock. Licensee will obtain safe toys and equipment available for children. The home is equipped with a working smoke detector and carbon monoxide detector. The charged fire extinguisher is rated at least 2A10BC. The home's backyard is fully fenced; part of it will be used for childcare. The side yard is off-limits and gated. There is no spa, pool, pond, or fountain on the premises. None shall be added without prior approval of the Licensing agency. Parents will be required to sign insurance affidavits if the provider does not plan to purchase additional child care liability insurance. Proof of control of property is on file. Parent's rights are posted. Emergency drills must be conducted at least once every six months and the date documented. LPA reviewed with L1 LIC 311D (Forms/Records to Keep in Your Family Child Care Home), children’s forms/records, facility forms/records, and information to be posted. The roster is to remain current at all times.
(Continued on LIC 809-C)
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2022
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 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NGUYEN, HOANG FCCH
FACILITY NUMBER: 493010145
VISIT DATE: 05/20/2022
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 Unusual Incident Report (UIR) procedures were explained, to include notification before close of next business day and follow-up with written report to: cclrpregionalofficegeneral@dss.ca.gov within seven days. L1 will maintain current pediatric CPR, First Aid, and child abuse mandated reporter training certification. L1 shall be present in the home and ensure that children in care are supervised by a fingerprinted adult with current pediatric CPR and First Aid certification. L1 understands that children may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. Infants and children shall not be allowed to sleep in car carriers in the home. L1 clearly understands the maximum number of children for whom care can be provided and the limitations on the number of infants (birth to age two years) that may be cared for and when two of the children in care must be school aged. Smoking is prohibited at all times in any area where child care is provided. L1 understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website http://ccld.ca.gov/. L1 understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice. LPA discussed the safe sleep regulations with L1 and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicants 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. 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 information related to licensed facilities, visit the CCLD website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.
Exit interview conducted and report was reviewed with applicant, Hoang “Kim” Nguyen.
This facility will be licensed once conditions of licensure are met:
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: NGUYEN, HOANG FCCH
FACILITY NUMBER: 493010145
VISIT DATE: 05/20/2022
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Exit interview conducted and report was reviewed with applicant, Hoang “Kim” Nguyen.
This facility will be licensed once conditions of licensure are met:

1. Since Licensee plans to provide care to infants, there must be one play yard/crib for each infant in care. Licensee will purchase one or two play yards/cribs and provide documentation to LPA at jennifer.velasco@dss.ca.gov

2. Licensee will provide safe toys and equipment to children in care. Licensee will obtain safe toys and equipment for children in care and provide documentation to LPA at jennifer.velasco@dss.ca.gov

3. Licensee plans to add outlet covers to the unused outlets in the family room.

4. Licensee plans to barricaded the 2nd fire place in the family room

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2022
LIC809 (FAS) - (06/04)
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