Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002577
Report Date: 01/13/2016
Date Signed 01/13/2016 05:13:07 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: 4DATE:
01/13/2016
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
04:40 PM
MET WITH:Marisol Negrete, Erika SamoyTIME COMPLETED:
05:20 PM
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LPA Andrea Medlin met with staff for this plan of correction visit established on 7/30/15. Purpose of the visit explained. There were 4 children during the visit; 2 infants and 2 preschool aged children. The previously cited deficiency was checked today:
  • Section 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. Last drill was conducted in August 2015 and logged. A sample form is given today to use for reference of logging emergency drills.

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) 266-8843
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8843
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2016
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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