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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493010146
Report Date: 05/12/2022
Date Signed: 05/12/2022 02:08:13 PM

Document Has Been Signed on 05/12/2022 02:08 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:PHAN, GINA & TONY FCCHFACILITY NUMBER:
493010146
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
05/12/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tony PhanTIME COMPLETED:
02:15 PM
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A prelicensing inspection was conducted today by Licensing Program Analysts Sebastian Phouthavong and Jennifer Velasco (LPAs). Applicants Gina Phan (L1) and Tony Phan (L2) are requesting a license for a capacity of eight children. Services will be available Monday through Friday, 7:00 a.m. – 5:30 p.m., year-round. L1 and L2 understand 24-hour consecutive care is prohibited. There are two adults living in the home. L1 and L2 were 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, backyard, second bedroom, and hall bathroom.The children will enter through a section of the garage with the rest of the garage will be render inaccessible with tall fixed partitions. Children will enter/exist the garage. The home being the area of care. The off-limits areas of the home include two bedrooms, one bathroom, laundry room, kitchen, utility closets, one section of the backyard, one side yard, backyard shed, and parts of the garage, made inaccessible by means of door knob covers, gates, fencing, and/or door locks. The home appears to be clean and orderly at this time and will remain so during childcare hours. There is a working telephone. The sharp knives, cleaning supplies, and medicines are stored out of the reach of children. L1 and L2 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. LPA observed 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 and 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 childcare 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 the LIC 311D with L2; 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: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PHAN, GINA & TONY FCCH
FACILITY NUMBER: 493010146
VISIT DATE: 05/12/2022
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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 and L2 will maintain current pediatric CPR, First Aid, and child abuse mandated reporter training certification. L1 and/or L2 shall be present in the home and shall ensure that children in care are supervised by a fingerprinted adult with current pediatric CPR and First Aid certification. L1 and L2 understand 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 and L2 clearly understand 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 childcare is provided.
L1 and L2 understand the responsibility to read and have knowledge of the laws and regulations for operation of a family childcare home. Forms and regulations must be obtained from the website http://ccld.ca.gov/. L1 and L2 understand 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 webpage 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 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.
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 applicants, Tony Phan.
This facility is approved for a small FCCH license effective today, 05/12/2022.
SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
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