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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012360
Report Date: 06/11/2019
Date Signed: 06/13/2019 09:12:50 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:GIM PLACEFACILITY NUMBER:
198012360
ADMINISTRATOR:MINA KIMFACILITY TYPE:
850
ADDRESS:15700 ROSECRANS AVENUETELEPHONE:
(714) 739-1198
CITY:LA MIRADASTATE: CAZIP CODE:
90638
CAPACITY:75CENSUS: 60DATE:
06/11/2019
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Ericka Byon, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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An announced required visit was conducted by the Licensing Program Analyst (LPA) Torrence on 06/11/2019 at 10:55 a.m. LPA met with Ericka Byon, Administrator who guided analyst on a tour of the facility inside and out. LPA discovered that a LIC 308 Designation of Facility Responsibility for Ericka Byon was not sent to the department within the required 10 days. LPA reviewed Ericka Byon’s teacher’s qualification and determined she met the department’s regulations for a fully qualified teacher. This facility is currently licensed for 75 children. Census was taken. There was a total of 60 preschool children and six staff present. Operation hours are 8:00 a.m. to 6:00 p.m. Monday to Friday.

During this visit, it was determined the facility is operating within its licensed capacity and within compliance of staffing ratio. A review of staff records indicates that Joosil Oh and He Kim have not received a criminal record clearance or exemption and a child abuse index clearance. LPA Torrence advised Ericka Byon, Administrator that both individuals must immediately leave the facility. LPA Torrence observed both individual leaving the facility. Since Administrator Erika Byon is a qualified teacher, she remained in the classroom until another teacher arrived.

The facility was reviewed to ensure compliance with license conditions and limitations, staffing and ratios, inaccessibility to poisons, medication, and hazardous items that can pose a danger to children. Equipment and furniture were inspected to ensure it's in good condition, free of sharp, loose or pointed parts. Toilets and sinks were inspected to ensure they are safe and in a sanitary operating condition, floors were inspected for safety and cleanliness. The playground was inspected for safety, good condition of equipment, including appropriate cushioning material. The kitchen, food-preparation and storage areas were clean. This facility provides breakfast, lunch, and a PM snack. Uncontaminated drinking water was readily available both indoors and outdoors.



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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: GIM PLACE
FACILITY NUMBER: 198012360
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2019
Section Cited
CCR
101170(e)(1)
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101170(e)(1) Criminal Record Clearance. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department.
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During this inspection, Jooseil Oh left the facility with a copy of the LIC 9163 Request for Live Scan to complete the fingerprint clearance process. Administrator provided He Kim with a copy of the LIC 9163. Per Administrator, she will submitt copies of the processed LIC 9163 as proof of completion of fingerprint. LPA ensure that the
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The requirement is not met as evidence by LPA Torrence review of Joosil Oh and He Kim records indicated that fingerprints have not been completed and are not cleared. This poses an immediate risk to the safety of children in care. A civil penalty of $500 for each staff is being assessed.
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Administrator understand that the staff member can not be at the facility until they are criminal record cleared. Per Administrator, she will submit proof to LPA by POC due date of 06/12/2019.
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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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: GIM PLACE
FACILITY NUMBER: 198012360
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/12/2019
Section Cited
CCR
101212(b)
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101212(b) Reporting Requirements. The name of the child care center director, and any fully qualified teacher(s) designated to act in the child care center director's absence, shall be reported to the Department within 10 days of a change of child care center director or designee(s). The requirement is not met as evidence by
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Per Administrator, she will submit a LIC 308 Designation of Responsiblity to LPA by POC due date.
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Director did not inform the department of the new appointed staff desginatee to act in the director's absence. This poses a potential risk to the safety of the children in care.
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Type B
06/12/2019
Section Cited
CCR
101217(a)
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101217 (a) Personnel Records. The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information.
The requirement is not met as evidence by record review and there were four staff records missing. Per Administrator, Director
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Per Administrator, the Director is returning the staff records to the facility tomorrow. Adminsitorator will submit proof that the staff file are returned to the facility to LPA by POC due date of 06/12/19.
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took staff records home to orgainize them. This poses a potential risk to the safety of chidlren in care.
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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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GIM PLACE
FACILITY NUMBER: 198012360
VISIT DATE: 06/11/2019
NARRATIVE
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Upon receipt of this report, the Licensee shall post the Notice of Site Visit and any Licensing report documenting a type “A” deficiency. The report and the Notice of Site Visit shall be posted for 30 consecutive days. Failure to maintain posting as required, will result in an immediate $100 civil penalty. A copy of this report shall be provided to the parent/guardian of children currently enrolled by the next business day or immediately upon return. A copy of this report shall also be provided to the parent/guardian of any newly enrolled children for the next 12 months (1 year). The Acknowledgement form must be maintained in each child’s file immediately upon receipt from parent. Licensee was provided with a copy of the parent Acknowledgement of Receipt of Licensing Reports Form during this visit. A copy of the Parent Notification Requirements was also provided to the Licensee.

Exit interview was conducted. Report reviewed and discussed. Appeal rights provided and explained. A copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights.

END OF REPORT
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: GIM PLACE
FACILITY NUMBER: 198012360
VISIT DATE: 06/11/2019
NARRATIVE
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Facility has a current disaster drill log. Fire extinguisher and carbon monoxide was located at this facility. Staff's files were reviewed for education verification, CPR/First Aid, and new immunization requirements for (MMR, Pertussis, and Flu vaccines). The facility currently has seven staff members; however, there were only three staff personnel records available to review. Per Administrator, the Director took the remaining staff records home to organize them. LPA was informed that all the staff members have not completed the mandated reporter training. Licensee was informed on how to access the training from website: www.mandatedreporterca.com. A sample of children's files were reviewed for completeness of admission agreement, verification of sign in/out including time the child was signed in/out by authorized representative as well as verification of representative’s full legal signature.

Incidental Medical Services-IMS was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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.htmThe updated plan of operation has been received in our office for providing Incidental Medical Services. (IMS).

Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov . Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.



The following deficiencies were cited per California Code of Regulations Title 22: 10117(e)(1) Criminal Record Clearance; 101217(a) Personnel Records, and 101212(b) Reporting Requirement, see 809-D. A Technical Violation Advisory was provided for H&S 1596.8662 Mandated Reporter Training.


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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5