Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002577
Report Date: 05/04/2017
Date Signed 05/04/2017 04:25:41 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:
05/04/2017
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Marisol Negrete, Erika SamoyTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
LPA Andrea Medlin met with staff for this plan of correction visit established on 3/17/17. Purpose of the visit explained. There were 9 children present during the visit; 3 infants and 6 preschool aged children. Some of the previously cited deficiencies have still not been corrected and are being re-cited today.

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.
SUPERVISOR'S NAME: Alma MaligTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Andrea MedlinTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2017
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 2


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: 05/04/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2017
Section Cited
102421
1
2
3
4
5
6
7
Section 102421: Child's Records: Some children's records are incomplete; C6, C8, and C9 need immunizations.
1
2
3
4
5
6
7
All children's records will be updated by 5/17/17.
Type B
05/17/2017
Section Cited
H&S 1597.622(a)
1
2
3
4
5
6
7
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.
1
2
3
4
5
6
7
All records will be available by 5/17/17.
8
9
10
11
12
13
14
Licensee is in process of getting all the staff immunizations.
8
9
10
11
12
13
14
Type B
05/17/2017
Section Cited
102416(c)
1
2
3
4
5
6
7
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 has expired First Aid and CPR certification.
1
2
3
4
5
6
7
Licensee shall have proof of enrollment in a First Aid and CPR course by 5/17/17 and copy of certificate sent to the licensing office after completion.
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: 05/04/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2017
LIC809 (FAS) - (06/04)
Page: 2 of 2