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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408128
Report Date: 12/15/2023
Date Signed: 12/15/2023 04:08:03 PM


Document Has Been Signed on 12/15/2023 04:08 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:CHIM-IN, PREEYAFACILITY NUMBER:
073408128
ADMINISTRATOR:CHIM-IN, PREEYAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 926-5144
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:14CENSUS: 8DATE:
12/15/2023
TYPE OF VISIT:Annual/RequiredUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Preeya Chim inTIME COMPLETED:
04:15 PM
NARRATIVE
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On 12/15/23 at 2:15 PM, Licensing Program Analyst (LPA) Sikia Blue arrived at the home for an unannounced Required Random Inspection. LPA met with Preeya Chim-In to explain the purpose of today’s visit. Present in the home was licensee and two assistants. Today census is 8 with 8 children enrolled. The facility operating hours are Monday-Friday 8:00am-5:30pm. Licensee provide meals for children in care and licensee was reminded of the importance of serving healthy food choices.

LPA toured the areas of the home used to provide care for children, to complete a health and safety inspection. The home is neat and clean with heating and ventilation for the safety and comfort of children in care. This is a single family home with 3 bedrooms and 2 bathroom home which consists of the living room, dining room, family room, kitchen, fenced backyard, and garage. The living room, family room, dining room, one bathroom and backyard which is used for outdoor play are the ON LIMIT areas. The OFF LIMIT areas are the 3 bedrooms, 1 bathroom, kitchen and garage. These areas are inaccessible to children in care by closed and/or locked doors, visual supervision and a safety gate at the bottom of the stairs. The ISOLATION area will be a section of the living room, away from other children in care. LPA observed that all the toys were neat and clean and equipment safe for children to play. The parent board is located behind the door for parents to see and has all the required documents at this time.

LPA observed an ample supply of age appropriate toys, equipment and furniture that appear to be safe and in good condition. LPA DID NOT observe any bodies of water. LPA DID NOT observe any hazardous materials, toxins or medications accessible to children today. The home is equipped with a smoke detector, carbon monoxide detector, working telephone, and fully stocked first aid kit. The fire extinguisher is a 2A-10-BC fully charged in the green area.

Continued on LIC809C

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Sikia BlueTELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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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Document Has Been Signed on 12/15/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: CHIM-IN, PREEYA
FACILITY NUMBER: 073408128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)
Operation of A Family Child Care Home
(a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times. When circumstances require the licensee to be temporarily absent from the home, the licensee shall arrange for a substitute adult to care for and supervise the children during his/her absence. Temporary absences shall not exceed 20 percent of the hours that the facility is providing care per day.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Sikia BlueTELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CHIM-IN, PREEYA
FACILITY NUMBER: 073408128
VISIT DATE: 12/15/2023
NARRATIVE
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PAGE 2 *************************************************************************************************
At 2:45 pm LPA asked licensee for CPR/First Aid certificates and Mandated reporter completion. CPR expires 01/2025 and mandated reporter expires 10/2025. LPA explained the importance of having these documents and keeping a record. The licensee stated that there are no firearms in the home.

At 2:45 PM applicant asked licensee if fire/earthquake drill have been conducted and the form filled out licensee stated they have conducted the required fire and safety drill and LPA observed the last drill was completed on 12/20/2022 which is more than 6 months ago. LPA explained the importance of completing drills and documenting it. Licensee confirmed that the emergency disaster plan is up to date. LPA reviewed four children’s files and found them to be complete with all required documents.

At 3:00 PM LPA Reviewed three personnel files and the files were missing CPR certifications and mandated reporter certificate. LPA informed licensee this will be a type B citation for not having the required trainings. The licensee was reminded that walkers, baby bouncers and drop down cribs are not allowed in day care facilities. LPA observed the Facility roaster and it has all children and is complete. LPA also observed the provider has a sleep plan and sleep log for one infant. The provider was informed of the importance of continuously making sure the sleep plan is filled out properly and accurately. LPA explained the importance of the roaster being current and up to date at all times for the facility records and needs to be kept for 3 years.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Continued on LIC 809C

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Sikia BlueTELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: CHIM-IN, PREEYA
FACILITY NUMBER: 073408128
VISIT DATE: 12/15/2023
NARRATIVE
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.


Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
Per Title 22, Division 12 Chapter 1 Article 6, of the California code of Regulations, The following deficiencies are being cited: 102417(a) and 102416(d)(1) (see 809-D)

Exit interview conducted at 4:00 pm, the Licensee confirmed that there are no Registered Sex Offenders living in the facility, and an RSO check and profile was completed by Licensing. Notice of site visit was given and must remain posted for 30 days. Report was reviewed and given to the licensee, Preeya Chim-In. Appeal rights were provided.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Sikia BlueTELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 12/15/2023 04:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612


FACILITY NAME: CHIM-IN, PREEYA
FACILITY NUMBER: 073408128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA was informed licensee was not home an at another job (THE SPA) out which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2024
Plan of Correction
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Licensee shall provide a statment of understanding of the regulation.
Type B
Section Cited
CCR
102416(d)(1)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above, Licensee and aisstant did not have the required CPR training completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/03/2024
Plan of Correction
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Licensee and aisstants shall taking required trainings a provide proof to LPA by email
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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Sikia BlueTELEPHONE: (510) 725-7006
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8