<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419328
Report Date: 03/02/2021
Date Signed: 03/02/2021 11:44:43 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: 4DATE:
03/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Heesook KimTIME COMPLETED:
11:54 AM
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 Lisa Dyer and LPM Loretta Dyson met with licensee Heesook Kim and her husband for a case management visit. Present for the visit were licensee, her husband and 4 children in care consisting of 2 infants and 2 preschool age children.

A review of staff records on 3/02/2021 indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearances except John Kim, who is the licensee’s son. Licensee states that her son John Kim currently lives in the home. Mr. Kim does not have a criminal record and child abuse clearance. Licensee states that her son Mr. Kim will be moving out of the home on April 1, 2021.

The attached type A deficiency is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parent/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

TODAY AN IMMEDIATE CIVIL PENALTY OF $500 IS ASSESSED BECAUSE LICENSEE’S ADULT SON J. KIM IS NOT ASSOCIATED TO THE FACILITY.

An exit interview was conducted. Licensee was provided a copy of her appeal rights.
SUPERVISOR'S NAME: Antranette RobinsonTELEPHONE: (510) -28-4353
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: KIM, HEESOOK
FACILITY NUMBER: 013419328
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2021
Section Cited

1
2
3
4
5
6
7
Criminal Record Clearance. All individuals subject to a criminal record review as specified pursuant to Health and Safety Code Section 1596.871 shall, prior to working, residing, or volunteering in a licensed facility...shall obtain a California clearance or a criminal record exemption as required by the Department.
8
9
10
11
12
13
14
THIS REQUIREMENT WAS NOT MET AS EVIDENCED BY OBSERVATION, INTERVIEW AND DOCUMENT REVIEW. BASED ON INTERVIEW AND DOCUMENT REVIEW LICENSEE’S ADULT SON, J. KIM, LIVES IN THE HOME AND IS NOT FINGERPRINT CLEARED NOR ASSOCIATED TO THE FACILITY. THIS POSES AN IMMEDIATE HEALTH AND SAFETY RISK TO CHILDREN IN CARE
8
9
10
11
12
13
14
Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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) -28-4353
LICENSING EVALUATOR NAME: Phyllis DyerTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2