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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198006430
Report Date: 11/12/2019
Date Signed: 11/12/2019 09:51:42 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:CHUNG FAMILY CHILD CAREFACILITY NUMBER:
198006430
ADMINISTRATOR:CHUNG, JUIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 396-1611
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY:14CENSUS: 7DATE:
11/12/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Jui ChungTIME COMPLETED:
10:00 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
Random inspection conducted by Licensing Program Analyst (LPA) Jennifer Hua. LPA Met with licensee, Jui Chung & her spouse Chi Lin who guided the analyst on a tour of the facility. This is a two story home. Residing in facility are 2 adults, licensee and her spouse. LPA observed 7 kids in care, supervised by licensee and her spouse. The facility operates M-F 8am - 6:30pm.

Areas accessible to children were inspected as follows: Living room, family room,
1 bath room, and fenced backyard.

Per licensee, there are no weapons, firearms, swimming pool or spa on the premises. The backyard is adequately fenced.

There are age appropriate toys and equipment on the premises. The smoke/carbon monoxide detectors and fire extinguisher (2A 10BC) are in operable condition. Fire extinguisher was purchased on 7/16/19
Areas off limits include: downstair bedroom, laundry room, kitchen, garage, front yard and second level. Safety gate at bottom of stairs. Licensee will install additional gate from dining room to kitchen entrance.
Licensee and spouse is current in Pediatric CPR/First Aid that will expire on 3/4/20.
Child Care Roster, Disaster Plan, Emergency Disaster Drill and Children's Records were reviewed. Drills conducted on 10/15/19.
Children records and required licensing forms were discussed as well as mandated child abuse reporting and criminal records clearance (finger prints and child abuse clearance) requirement.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2019
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 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME: CHUNG FAMILY CHILD CARE
FACILITY NUMBER: 198006430
VISIT DATE: 11/12/2019
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
26
27
28
29
30
31
32
Rooms that are off-limits need to be made inaccessible during operating hours. No smoking, No infant walkers, Johnny jumpers, exersaucers, bouncers and any other item that falls into that category, earthquake – fire, disaster drills and safety, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal records, child abuse clearance and criminal records transfer requirements, SIDS, Never Shake A Baby, A Child Care Provider's Guide to Safe Sleep was provided and discussed with licensee. Affidavit for Liability Insurance form in children's files. Licensee was informed to complete the Mandated Reporter Training online at http://www.mandatedreporterca.com/ once training is available in her language. .

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) 514-0388 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

· Dog(s) and or pets should be isolated from children in care. No pets observed.
· It is recommended that a First Aid kit be available on premises.
Outdoor supervision required at all times. If outdoor area not adequately fenced provider must be with children at all times when outdoors.

No deficiencies cited.

Exit interview was conducted with licensee.

Site visit notice posted. And Licensee advised to keep notice posted for 30 days.
Web site address to order forms: http://www.dss.cahwnet.gov/cdssweb/On-lineFor_293.htm#l
INTERNET ADDRESS: http://www.ccld.ca.gov – To access licensing forms, updates and Title 22.
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2019
LIC809 (FAS) - (06/04)
Page: 2 of 2