Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002577
Report Date: 06/01/2017
Date Signed 06/01/2017 05:15:39 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: 10DATE:
06/01/2017
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Rina PhouTIME COMPLETED:
04:55 PM
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LPA Andrea Medlin met with Licensee and helpers for this plan of correction visit established on 4/14/17 and 5/4/17. Purpose of the visit explained. The following previously cited deficiencies were checked today:
  • 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 scheduled to take the Pediatric First Aid and CPR training on 6/10/17. Licensee will forward copies of completed Pediatric First Aid and CPR to the licensing office once completed.
  • Section 102421: Child's Records: Children's records are complete now.
  • Section 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 has verification of the staff immunization records.

This report was reviewed with Licensee and a 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: 06/01/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2017
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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