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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198016990
Report Date: 08/08/2022
Date Signed: 08/08/2022 11:05:41 AM


Document Has Been Signed on 08/08/2022 11:05 AM - It Cannot Be Edited

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:KIM FAMILY CHILD CAREFACILITY NUMBER:
198016990
ADMINISTRATOR:KIM, HYEI JINFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 242-7777
CITY:GLENDALESTATE: CAZIP CODE:
91201
CAPACITY:14CENSUS: 4DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Hyei Jin KimTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Anomeh Eivazian conducted an unannounced annual inspection to the above facility on 08/08//2022. LPA arrived at the facility at 8:20 AM and met with Hyei Jin Kim, Licensee who guided analyst on a tour of the facility. Also present during this inspection, was Si Choi, Licensee’s Assistant. Per licensee, Hyei Jin Kim facility hours are Monday to Friday from 7:30 a.m. to 5:30 p.m. LPA provided a copy of Entrance Checklist—Family Child Care Home (LIC126) to licensee.

This is a one story home which consists of 3 bedrooms, 2 bathrooms, kitchen, dining room, living room (FIREPLACE: inaccessible),laundry room, detached room (storage) in the backyard, front yard and backyard (fenced). Per licensee the children use the living room, dining room, one bedroom adjacent to the living room, bathroom in the hallway of bedrooms, kitchen, and backyard (fenced). Per licensee areas off limits to children and parents include: 2 bedrooms, one bathroom in the master bedroom, detached room (storage) in the backyard, and front yard. LPA did not observe any stairs in the home. During this inspection individuals who reside in the home were discussed and notes on Confidential Name List (LIC811) and attached to this report.

All areas identified on the facility sketch that are accessible for children to use were inspected for safety, comfort, and cleanliness. At 8:45 a.m., Licensee took this LPA on a tour of the home. LPA was toured through the interior starting with the living room and dining room (daycare classrooms), LPA observed children's table, chairs, and toys in the dining room and living room. LPA observed all electrical outlets were covered in living room and dining room. LPA observed four children in the living room with licensee and her assistant. Next LPA toured the one daycare bedroom and observed children toys in the bedroom. Next LPA toured the one daycare bathroom in the hallway of bedrooms and observed child proof safety latches on the cabinets under the sink where licensee stores cleaning compounds and personal items. Next LPA toured the kitchen and observed child proof safety latches on the cabinets where licensee stores sharp items and cleaning compounds. LPA observed plastic door knobs on off-limit two bedrooms doors. LPA observed the required 2A 10BC fire extinguisher was placed on the floor in the dining room. Per licensee, it was purchased on 07/2022 he receipt, licensee was not able to locate the receipt.
REPORT CONTINUES ON NEXT PAGE 1 of 5
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
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 7


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: KIM FAMILY CHILD CARE
FACILITY NUMBER: 198016990
VISIT DATE: 08/08/2022
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Licensee tested the carbon monoxide and smoke detectors in the living room. Both sounded off the alarms and heard by LPA to be functional. Detergents, cleaning compounds, medications, and other items which could pose a danger to children were observed to be inaccessible to children. The licensee states that there are no poisons in the home and understands that storage areas for poisons must be locked with a key or combination lock.

Next LPA toured the backyard fenced. Currently, children are using the back yard for outdoor play time. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that can pose a danger to children on the outdoor yard. The licensee states that supervision is always provided.

Per Licensee, Hyei Jin Kim at 9:30 a.m there are no pets, weapons, firearms, pools, spas, hot tubs, fish ponds, or similar bodies of water on the premises.

The licensee was observed to be operating within the licensed capacity and is not exceeding the required limitations during this inspection. During this inspection 4 children were present in the home with licensee and her one assistant. Licensee, her husband and her assistant, adults present have obtained a criminal record clearance on Licensing Information System (LIS). However, licensee's son, David Lee (adult) who was present in the home during this inspection did not have criminal record clearance on Licensing Information System (LIS). Per licensee, currently she has one assistant. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

The licensee and other personnel did not complete training on preventive health practices including Pediatric First Aid and CPR. The licensee did not have current Pediatric First Aid and CPR certificate available during this inspection. Licensee did not complete required mandated reporter training and did not have required mandated reporter training certificate on file during this inspection. There are first aid supplies available on the premises in the dining room in a closet. LPA advised licensee that if a child shows signs of illness he/she/they shall be separated from other children.
REPORT CONTINUES ON NEXT PAGE 2 of 5
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: KIM FAMILY CHILD CARE
FACILITY NUMBER: 198016990
VISIT DATE: 08/08/2022
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At 10:00 a.m., facility roster was reviewed and completed. Per licensee currently there are 4 children enrolled. LPA reviewed 4 children's records, including emergency information from 4 enrolled children, and all 4 reviewed files were completed. The licensee and her assistant have proof of immunization against influenza, pertussis, and measles.

All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. Last drill documented was conducted on 03/25/2022. Emergency Disaster Plan, Parent’s Rights Poster and the Facility License were observed to be posted at the wall by the entrance.

LPA did not observe the following items during the inspection: Infant Walkers, Johnny Jumpers, Saucer Chairs, Trampolines and/or any other item that fall into these categories are not permitted in a family child care facility. Smoking is prohibited in a licensed Family Child Care Home. Per Licensee, no one smokes in the home. There is telephone service via a cellphone that is used and the cellphone stays at the facility during operation hours. Per licensee she carries liability insurance or a bond in accordance with standard established by Family Child Care statue.

INFANT CARE: Licensee states that she is caring for infants over one year old, Per licensee, currently she does not have any infants enrolled in her daycare. Licensee states that if an infant is enrolled, the infant will sleep in the daycare bedroom and living room where they are constantly supervised. Appropriate sleeping arrangements and cribs will be available. (one crib for each infant in care is required). Cribs or play yard shall not hinder the entrance or exit from the sleeping space, mattresses shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Cribs and play yards shall be free of loose articles and objects. No objects shall be hanging above or attached to the side of the crib. LPA did not observe any infants swaddled while in care. LPA advised the Licensee that infants shall be placed on their backs for sleeping and shall be supervised. Infants shall be checked on every 15 minutes and the time of each 15-minute check shall be documented with child’s name and date. The LIC 9227 Individual Infant Sleeping Plan shall be completed for each infant up to 12 months of age. A copy of the LIC 9227 was provided to Licensee. LPA provided the licensee with a copy of A Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. LPA also consulted and explained Child Abuse Reporting, Never Shake a Baby, and Safe Sleeping practices.
REPORT CONTINUES ON NEXT PAGE 3 of 5
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: KIM FAMILY CHILD CARE
FACILITY NUMBER: 198016990
VISIT DATE: 08/08/2022
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SAFE SLEEP: LPA discussed the safe sleep regulations with licensee, and discussed the Child Care Licensing Safe Sleep webpage at http://www.cdss.ca.gov/inforescources/child-care-licensing/public-information-and-resoucrces/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at http://www/cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Boppy recall: https://www.cpsc.gov/Recalls/2021/The-Boppy-Company-Recalls-Over-3-Million-Original-Newborn-Loungers-Boppy-Preferred-Newborn-Loungers-and-Pottery-Barn-Kids-Boppy-Newborn-Loungers-After-8-Infant-Deaths-Suffocation-Risk

Medication: Incidental Medical Services (IMS) policy was discussed. The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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.

LPA advised the licensee to access forms, regulations and quarterly updates online at: www.ccld.ca.gov. LPA also discussed the Provider Information Notices (PINS) on Safe Sleep Awareness: PIN 19-02-CCP,
U.S. CONSUMER PRODUCT SAFETY COMMISSION FISHER-PRICE INFANT EQUIPMENT RECALLS: PIN 20-19 CCP COVID FAQ - PIN 20-11-CCP, Required Lead Testing: PIN 20-01 CCP Effects of Lead Exposure, and Guardian User Account Access - PIN 20-20-CCLD. PIN 22-10- CCP-- UPDATED GUIDANCE FOR CHILD CARE PROVIDERS REGARDING CORONAVIRUS DISEASE (COVID-19)

The following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.
REPORT CONTINUES ON NEXT PAGE 4 of 5
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7
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: KIM FAMILY CHILD CARE
FACILITY NUMBER: 198016990
VISIT DATE: 08/08/2022
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LPA Eivazian informed licensee Hyei Jin Kim that this report dated 08/08/2022 documents 1 Type A citation Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Eivazian informed the licensee to provide a copy of this licensing report dated 08/08/2022 that documents 1 Type A citation to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

The Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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


Exit interview conducted and report was reviewed with the Licensee, Hyei Jin Kim at 11:20 a.m..
REPORT END 5 of 5
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 08/08/2022 11:05 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: KIM FAMILY CHILD CARE
FACILITY NUMBER: 198016990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102370(d)
Criminal Record Clearance
(d) 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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above and licensee's son, adult, David Lee did not have criminal record clearance on Licensing information System (LIS) which poses an immediate health, safety or personal rights risk to persons in care.
$500 Civil Penalty was accessed today.
POC Due Date: 08/09/2022
Plan of Correction
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Per licensee, her son will complete the required criminal record clearance today and a copy of livescan form will be submitted to LPA Eivazian by plan of correction due date 08/09/22.
Section Cited
Deficient Practice Statement
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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: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 08/08/2022 11:05 AM - 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754


FACILITY NAME: KIM FAMILY CHILD CARE
FACILITY NUMBER: 198016990

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review, the licensee did not comply with the section cited above and did not have required mandated reporter training certificate on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Per licensee she will complete required mandated reporter training by plan of correction due date 08/31/22 and a copy will be submitted to LPA Eivazian via email.
Training can be completed at www.mandatedreporterca.com
Type B
Section Cited
CCR
102416(c)

(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 LPA's file review, the licensee did not comply with the section cited above and did not have required Pediatric First Aid and CPR which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2022
Plan of Correction
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Per licensee, she will complete the required pediatric first aid and CPR by plan of correction due date 08/31/22 and a copy will be submitted to LPA Eivazian via 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: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Anomeh EivazianTELEPHONE: (323) 981-3391
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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