Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312602
Report Date: 11/06/2015
Date Signed 11/06/2015 01:52:41 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:PHAN, JENNYFACILITY NUMBER:
304312602
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
11/06/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jenny Phan, LicenseeTIME COMPLETED:
02:00 PM
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LPA Jane Cong-Huyen met with licensee, Jenny Phan, for a random annual visit in accordance to Title 22 using KIT1. The visit was conducted in Vietnamese. LPA toured areas of the home inside and outside and areas accessible to the children. The home is a one level home with 3 bedrooms and 2 bathrooms. Licensee stated that OFF LIMITS areas include: master bed & master bath, bedroom to the left of hall way, garage and both side yard area. Licensee acknowledged that children may never enter these off-limit areas. The census includes 6 daycare children with ages ranging from 1 to 4 years old. (2 infants and 4 preschoolers) Licensee stated there are no new residents in the home since licensed. Also present in the home is the adult assistant who has fingerprint clearances. Licensee stated that she is not registered with any Foster Care agency. A review of staff records on this date indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was able to show proof of CPR and First Aid (exp: 11/9/15) that is EMSA certified for herself as well as for her assistant. LPA observed posted Parent's Rights and current disaster plan. LPA also reviewed children's records and children's roster. Fireplace is screened. Licensee stated there are no weapons in the home. LPA observed all sharp utensils, hazardous chemicals and medication are stored up high or in latched/locked cabinet which is inaccessible to children in care. Fire extinguisher, carbon monoxide detector and smoke detector meet regulations. LPA reviewed records/files during today's visit. The home has no pets at this time. The home has not bodies of water. LPA explained to the licensee about Incidental Medical Services (IMS). She stated that at this time she has not children that needs IMS and is not planning to provide IMS in her daycare in the future. If she changes her mind, she will contact Licensing.
No deficiency cited during today's visit.
Exit interview was conducted. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. LPA informed the director of how to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2015
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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