Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312602
Report Date: 10/18/2017
Date Signed 10/18/2017 12:19:56 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:PHAN, JENNYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 724-7545
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:14CENSUS: 3DATE:
10/18/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:46 AM
MET WITH:Jenny PhanTIME COMPLETED:
01:00 PM
NARRATIVE
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(2) LPA Thuy Ho met with licensee, Jenny Phan, for a random annual inspection in accordance to Title 22. 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 3 day care children with ages ranging from 1 to 4 years old. (3 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 provide proof of CPR and First Aid (exp: 11/9/17) 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 and smoke detector are in operation condition. LPA reviewed records/files during today's inspection. The home has no pets at this time. The home has no bodies of water.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: PHAN, JENNY
FACILITY NUMBER: 304312602
VISIT DATE: 10/18/2017
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

After a tour of the home and review children and staff's records, no deficiency was observed.



Exit interview was conducted. The Notice of Site Visit was posted. Licensee 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. L

Hard copy and link of Child Care Providers Guide to Safe Sleep provided to licensee on this day: https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

Web address for downloading forms or regulations was provided as (http://ccld.ca.gov/PG411.htm).

Any proposed changes to the physical plant, including telephone number, shall be immediately reported to the Department.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Thuy HoTELEPHONE: (714) 703-2824
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2017
LIC809 (FAS) - (06/04)
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