Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 384002528
Report Date: 05/22/2015 12:00:00 AM
Date Signed 05/22/2015 01:47:31 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LUONG, NGOC KHANHFACILITY NUMBER:
384002528
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
05/22/2015
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Ngoc Luong and Sandra MarquesTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Basi met with Licensee Ngoc Luong and Sandra Marques for this Case Management visit. The purpose of the visit was explained. Present in the facility today are six children, three staff are supervising children. Licensee has submitted an application for a Large Family Child Care Home. The fire clearance was granted on 03/27/2015. Licensee has submitted a complete LIC 9149 Property Owner/Landlord Consent Family Child Care Home form to expand to Large Family Child Care Home. LPA inspected the home for health and safety hazards. The licensee is adding the backyard and an additional room for care. The areas to be used for care are three rooms, children's bathroom and the backyard. LPA inspected all areas of the home that provide care and supervision to children.


Prior to approval for a Large Family Child Care Home licensee must:

Remove the construction supplies from the backyard.
SUPERVISOR'S NAME: Suzanne Roman-ClarkTELEPHONE: (650) 266-8823
LICENSING EVALUATOR NAME: Rajind BasiTELEPHONE: (650) 266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2015
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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