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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419328
Report Date: 11/25/2019
Date Signed: 12/16/2019 10:03:35 AM

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, HEESOOKFACILITY NUMBER:
013419328
ADMINISTRATOR:KIM, HEESOOKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 533-3922
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:14CENSUS: 5DATE:
11/25/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Hee Sook KimTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst Susan Neeson met with Heesook Kim and her husband Phillip (Muyoung) Kim for an unannounced annual random inspection visit. The visit began at 11:30 AM. There are 4 adults fingerprint clear and associated with the facility. According to Hee Sook Kim she resides here with her husband and adult son.

There are 4 infants and 1 preschool child present. Children's records were reviewed. Licensee and her husband have Mandated Reporter Training certificates. CPR and First Aid are current for Mr. & Mrs. KIm. The home was toured for a health and safety inspection.

The home is a two story home. The home consists of a living room, dinning room, kitchen, 3 bedrooms, 2 bathrooms, children's play room, basement, fenced front yard and fenced back yard. Off-limits areas are one bedroom and the upstairs bedroom and bathroom occupied by the son. Day care areas are both yards, living room kitchen, one bedroom and the downstairs play room,There is a 2A10BC fire extinguisher, a working carbon and smoke detectors. There are no pools, spas, hot tubs, fish ponds or similar bodies of water. All poisons, detergents, cleaning compounds and medications are stored in areas which are inaccessible to children. The home has a fireplae in which there is a metal barricade in front of it and a sofa up against it. The home is clean and orderly with heating and ventilation. There is a gate to prevent the children from going to the children's play room and to the master bedroom. Licensee is present and allowed LPA to inspect the entire facility. The family has no pets. None of the required forms are posted. . First Aid and CPR certificates are current and expires 11/2/21. Mrs. Kim will use her fenced back yard for outdoor play. There are no pets. Facility has central heat. Facility has no pets.

Licensee is reminded that ALL assistants, volunteers, frequent visitors, or adults living in the home,
that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov and for day care updates visit www.myccl.ca.gov
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2019
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: KIM, HEESOOK
FACILITY NUMBER: 013419328
VISIT DATE: 11/25/2019
NARRATIVE
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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

The following documents were issued and discussed: Capacity sheet for large license, blue immunization forms, Flu prevention information, Quarterly update from Department, AB 1207 information, Safe Sleep for infants, Fire/earthquake drill information, Safe and healthy diapering, Parents Rights, Licensee rights & items not allowed in FCCH. Full packet of all forms were also issued and discussed.



Deficiencies are cited on LIC 809 D.

Appeal Rights were discussed.

An exit interview was given.

REPORT WAS NOT ISSUED DURING VISIT DUE TO MECHANICAL MALFUNCTION.


SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2019
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: KIM, HEESOOK
FACILITY NUMBER: 013419328
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/26/2019
Section Cited

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Criminal Record Clearance. All individuals subject to a criminal record review as specified in Section 1596.871 prior to working, residing or volunteering in a licensed home, shall obtain a California clearance or a criminal record exemption as required by the Department.
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This was not met in that John Kim has been residing here for 2 months and does not have fingerprints that are associated with the facility.
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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: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2019
LIC809 (FAS) - (06/04)
Page: 2 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: KIM, HEESOOK
FACILITY NUMBER: 013419328
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/25/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2019
Section Cited

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Smoking Prohibition (a) Smoking is prohibited on the premises of a family child care home as specified in Health and Safety Code Section 1596.795(a). This was not met in that there was smoking in the Son's room and smoke was could be smelled in the kitchen.
Type B
12/09/2019
Section Cited

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Immunization. Licensee shall document and maintain each child’s immunizations as long as the child is enrolled.
This was not met in that most of the children enrolled did not have immunizaons or they were not current.

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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: Antranette RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Susan NeesonTELEPHONE: (510)622-2630
LICENSING EVALUATOR SIGNATURE:
DATE: 11/25/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/25/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4