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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013411428
Report Date: 06/07/2023
Date Signed: 06/07/2023 12:02:47 PM


Document Has Been Signed on 06/07/2023 12:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:KIM, HELENFACILITY NUMBER:
013411428
ADMINISTRATOR:KIM, HELENFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 295-8780
CITY:BERKELEYSTATE: CAZIP CODE:
94704
CAPACITY:12CENSUS: 3DATE:
06/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Helen KimTIME COMPLETED:
12:10 PM
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On 06/07/2023 at 09:25 AM Licensing Program Analyst (LPA) Diana Campos conducted an unannounced Annual Required inspection at Helen Kim Family Childcare Home. LPA met with Licensee and explained the purpose of today's inspection. LPA was granted the inspection authority to enter the Home. The family childcare home days and hours of operation are Monday to Friday 08:00 AM to 06:00 PM. Present in the home at time of inspection were licensee, her mother, and 3 children in care including 1 preschooler and 2 infants.

Indoor Space: At 10:00 AM a health and safety tour of inside the home was done. LPA toured the premises with licensee. The home is sanitized and orderly in compliance with Title 22 Regulations at this time. There is a 2A10BC fire extinguisher, smoke and carbon monoxide detector in the home. The home is a one story house consisting of 2 bedrooms, 1 bathroom, living room, dining room, eat-in kitchen, and detached garage.



The OFF-LIMIT areas are the bedroom to the right of the bathroom and the detached garage. These areas are inaccessible to children in care by closed locked doors and visual supervision.
IN-USE The living room, dining room, kitchen, bathroom, bedroom to the left of bathroom and backyard is used as the primary areas for day-care. Medicines, cleaning products, sharp objects are stored inaccessible to children during today's inspection. LPA reminded licensee that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. Licensee states that there are no pets and arms and ammunition stored in the home. The fireplace is blocked to prevent access by children in care, and the home maintains a working telephone.
Outdoor Space: AT 10:30 AM LPA toured the outdoor area backyard and observed it was fenced. LPA observed there are no pools, hot tubs or other bodies of water.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2023
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: KIM, HELEN
FACILITY NUMBER: 013411428
VISIT DATE: 06/07/2023
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Children files and Facility files were reviewed. Facility contained Children's Roster and a copy was obtained. Licensee’s mandated reporter training expires 5/2025.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was 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 was 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



LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

No deficiencies cited during today's inspection.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Helen Kim.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Diana CamposTELEPHONE: (510) 873-6322
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2023
LIC809 (FAS) - (06/04)
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