Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002577
Report Date: 07/30/2015 12:00:00 AM
Date Signed 07/30/2015 01:35:04 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:PHOU, RINAFACILITY NUMBER:
414002577
ADMINISTRATOR:PHOU, RINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(415) 724-4757
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:14CENSUS: 9DATE:
07/30/2015
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Marisol NegreteTIME COMPLETED:
01:35 PM
NARRATIVE
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(3) LPA Andrea Medlin met with staff for this random annual licensing visit today. Licensee is not present during the visit. Purpose of the visit was explained. Days and hours of operation: Monday-Friday 7:30AM-5:30PM. There were 9 children present during the visit; 3 infants and 6 preschool aged. Per staff, Licensee and two minor children live in the home; criminal record clearance is on file for all adults in the home. Physical plant toured to inspect for health and safety hazards in the licensed areas. Outdoor space inspected for health and safety hazards; outdoor play area is completely fenced. The daycare has a fully charged fire extinguisher that meets the minimum requirements, smoke detectors, and carbon monoxide detectors in the daycare. Adequate first aid supplies are available. Detergents, cleaning compounds, medications, and other items which could pose a danger to children is stored inaccessible to children. The daycare area is kept clean and orderly and has adequate heating and ventilation for safety and comfort. Per staff, there are no firearms or weapons in the home. No spas, swimming pools, hot tubs, fish ponds, or similar bodies of water are present. Variety of age appropriate toys and materials is observed in the daycare. A sick child would be separated from the group and wait for parent to pick up. Licensee, and helper, have documentation of current Pediatric First Aid and CPR (exp 5/2017 and 2/2016) for Licensee or helper. A children's roster is available. No emergency disaster drill logs available for review. LPA gave a sample form to use to log emergency drills and reminded Licensee of the licensing requirement regarding drills which is required at least once every six months and document the drills. Children's records reviewed. In the files that were reviewed, all had a copy of immunization records and documentation of parent's rights. All the required licensing forms are posted in a prominent location.

The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 12, Chapter 1.

This report was reviewed with staff and a copy of this report must be made available for public review upon request.

Notice of Site Visit shall remain posted for 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2015
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PHOU, RINA
FACILITY NUMBER: 414002577
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2015
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2015
Section Cited
102417(g)(9)(A)
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102417(g)(9)(A) - Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill.


No emergency drill logs available for review.
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Conduct an emergency drill with children and send a copy of log to the licensing office by 8/12/15.
08/12/2015
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8832
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2015
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2015
LIC809 (FAS) - (06/04)
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