Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002577
Report Date: 03/17/2017
Date Signed 03/17/2017 04:41:03 PM

COMPREHENSIVE INSPECTION
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: 10DATE:
03/17/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Marisol Negrete, Erika SamoyTIME COMPLETED:
04:45 PM
NARRATIVE
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LPA Andrea Medlin met with two helpers for this random annual licensing visit. Purpose of the visit explained. The Licensee is not present during the visit. Daycare is operating over capacity today. There were 10 children present during the visit; 5 infants and 5 preschool aged. Physical plant toured to inspect for health and safety hazards. The daycare has a fully charged fire extinguisher in the home that meets the minimum requirements, smoke detector, and a carbon monoxide (CO) detectors in the home. Per staff, there are no firearms or weapons in the home. No pools, spas, hot tubs, fish ponds, or similar bodies of water are present. No documentation any staff with current Pediatric First Aid and CPR certification. No children's roster available. No documentation of emergency disaster drills. No verification of staff immunizations. Children's files are all incomplete and need current immunizations; some children have no files available. All the Parent's Right's forms have the wrong licensing office contact information. Incidental Medical Services (IMS) policy 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 is 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. Facility informed that effective September 1, 2016, a person may not be employed or volunteer at a child care facility unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption pursuant to Health and Safety code 1596.7995 and 1597.662.

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 shall be made available for public review upon request.

Due to Type A violations, this report and violations must be given to all parents and documented on the LIC 9224 and returned to each child's file. Notice of Site visit observed posted and shall remain posted for 30 days.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2017
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4


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: 03/17/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2017
Section Cited
H&S 1596.817
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§ H&S 1596.817: Posting Requirements: None of the required licensing forms are posted. Parent's Rights (LIC 995A), Emergency Disaster Plan (LIC 610), and License are not posted.
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Licensee shall post all of these documents in a prominent accessible location to parents by 4/17/17.

A return visit will be made to verify corrections
Type B
04/17/2017
Section Cited
102419(d)
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102419(d) Parental and Authorized Representative's Rights: At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parents’ Rights, LIC 995A.
The Parent's Rights forms need to have the correct licensing office contact information.
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Licensee shall ensure all children's files have documentation of Parent's Rights (LIC 995A) with correct licensing office contact information in their files by 4/17/17.
San Bruno Child Care Regional Office
851 Traeger Ave, Suite 360
San Bruno, CA 94066
(650) 266-8800
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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) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2017
LIC809 (FAS) - (06/04)
Page: 4 of 4


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: 03/17/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2017
Section Cited
102418(g)
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102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.

Children are missing immunizations records or are not updated. See LIC 811 dated 3/17/17 for a list of children's names.
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All children shall have complete immunization records on file by 4/17/17.


A return visit will be conducted to verify correction.
Type B
04/17/2017
Section Cited
H&S 1597.622(a)
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Employee and Volunteer Immunization: H&S 1597.622 (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
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See below
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Licensee and helpers do not have verification of the required staff immunizations.
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Licensee will correct by 4/17/17.

A return visit will be conducted to verify correction.
Type B
04/17/2017
Section Cited
102416(c)
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102416(c) Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. No staff present during visit with verification of Pediatric First Aid and CPR certification.
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Licensee to correct by due date of 4/17/17.

A return visit will be conducted to verify correction.
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) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2017
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: 03/17/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/20/2017
Section Cited
102416.5(a)
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102416.5(a) Staffing Ratio and Capacity. The capacity specified on the license shall be the maximum number of children for whom care can be provided.

Facility is operating over capacity. There are 5 infants and 5 preschool aged children. There may never be more than 4 infants in the daycare.
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Facility will lower capacity, or adjust children's schedules, to maintain ratios as specifed on the License.

A return visit will be conducted to verify correction.
Type B
04/17/2017
Section Cited
102417(g)(9)(A)
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102417(g)(9)(A)(1) 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 documenation of any emergency drills.
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Licensee to conduct an emergency disaster drill no later than 4/1717 and log the date and time of drill. Licensee is required to conduct emergency disaster drills at least once every six months.

A return visit will be conducted to verify correction.
Type B
04/17/2017
Section Cited
102421
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Child's Records: All childrens records are incomplete. Some children have no files. See LIC 811 dated 3/17/17 for a list of children's names.
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Licensee to have a complete file for each child and maintain the child's file for 3 years after child leaves facility.

A return visit will be conducted to verify correction.
Type B
04/17/2017
Section Cited
102417(g)(8)
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102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children.

No children's roster available.
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Licensee to complete a current children's roster by 4/17/17.

A return visit will be conducted to verify correction.
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) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2017
LIC809 (FAS) - (06/04)
Page: 2 of 4