Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002577
Report Date: 04/14/2017
Date Signed 04/14/2017 05:11:45 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: 1DATE:
04/14/2017
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Rina Phou, Marisol NegretteTIME COMPLETED:
05:20 PM
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LPA Andrea Medlin met with staff, and later Licensee, for this plan of correction visit established on 3/17/17. Purpose of the visit explained. There was one child in care during the visit. The following previously cited deficiencies were checked today:
  • Section 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 was in compliance with ratios today.
  • Section 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. Licensee conducted and emergency drill and it is logged.
  • Section 102421: Child's Records: Some children's records are incomplete; C6, C8, and C9 need immunizations.
  • Section 102417(g)(8) Operation of a Family Child Care Home. All homes shall have a current roster of the children. A current children's roster is available.
  • Section 102418(g) Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled. C6, C8, and C9 need updated immuniztions.
  • H&S Code 1597.622(a) - Employee and Volunteer Immunization: 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. Licensee is in process of getting all the staff immunizations.
  • Section 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. Licensee is in process of renewing the Pediatric First Aid and CPR training and will send to licensing once confirmed date.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2017
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PHOU, RINA
FACILITY NUMBER: 414002577
VISIT DATE: 04/14/2017
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This report was reviewed with Licensee and copy of this report must be made available for public review upon request.

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: 04/14/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2017
LIC809 (FAS) - (06/04)
Page: 2 of 2