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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019997
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:40:53 AM


Document Has Been Signed on 01/26/2023 11:40 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 CENTER DR 200B
MONTEREY PARK, CA 91754



FACILITY NAME:CHIM FAMILY CHILD CAREFACILITY NUMBER:
198019997
ADMINISTRATOR:LESLIE CHIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 896-7510
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY:14CENSUS: 7DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Leslie ChimTIME COMPLETED:
11:50 AM
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On January 26, 2023 at 9:00 AM, Licensing Program Analyst (LPA) Monique Ayala conducted an unannounced inspection at the facility noted above and met with Licensee, Leslie Chim. The purpose of the inspection was to conduct the Required - 1 Year inspection. The operating hours of the facility is Monday through Friday from 7:00 AM to 5:30 PM. Entrance Checklist (LIC 126) was provided to the Licensee upon arrival. Individuals residing in the home were discussed and noted. At the time of the inspection, the Licensee, Licensee's Assistant/Staff (S1), and seven (7) children were present.

All areas identified on the facility sketch were inspected. This facility is a single family home that consists of four (4) bedrooms, two (2) bathrooms, living room, dinning room, kitchen, detached garage, and fenced backyard.

Areas that are accessible to children include: 2 bedrooms, one (1) bathroom, living room, dining room, and fenced backyard. Per Licensee, the children utilize the fenced backyard for outdoor activity.

Areas off-limits to children include: 2 bedrooms, 1 bathroom (located in master bedroom), kitchen, gated area in the backyard, and detached garage. LPA observed the doors to the off-limit bedrooms closed and locked, making the areas inaccessible to children in care. LPA observed a child safety gate installed making the kitchen inaccessible to children in care. LPA also observed the backyard patio and an area in front of the garage located near the patio gated, making a separate space in the backyard inaccessible to children in care. Licensee was advised that off-limit areas must be made inaccessible during operating hours or while children in care are present.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique AyalaTELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997
VISIT DATE: 01/26/2023
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The following documents were posted in a prominent, publicly accessible area: Facility License, Notification of Parents' Rights (PUB 394), and Emergency Disaster Plan (LIC 610A). The Licensee had a current Facility Roster (LIC 9040) available for review. Licensee did not have verification of Disaster and Fire Drills available for review.

Areas used by children were inspected for safety, comfort, heating, cleanliness and telephone service. The home does not have any wall heaters. LPA observed a fire place in the living room that was barricaded by a cubby. Per Licensee, the fireplace is not operable. The home is equipped with central air and heating. Detergents, cleaning compounds, and medicines were made inaccessible to children. Per Licensee, there are no poisons kept in the home. Licensee was advised that if any poisons are purchased, it is required to be locked with a key or combination lock. Per Licensee, there are no pets or bodies of water on the premises. LPA observed age appropriate toys and napping equipment for children. LPA also observed electrical outlet covers installed in the child care areas.

LPA observed the required fire extinguisher (2-A:10-B:C) that is fully charged and was last serviced on August 24, 2022. Licensee was reminded to have the fire extinguisher serviced yearly. Smoke detector and carbon monoxide detector was tested and is operable. First Aid kit and emergency supplies are available and kept in the kitchen. Licensee was reminded that food that is brought from the child's home shall be labeled with the child’s name and properly stored or refrigerated.

LPA conducted a record review of five (5) children's records and 2 personnel records. Based on the children's record review, child (C1) did not have a completed Consent for Emergency Medical Treatment (LIC 627), C3 did not have an immunization record, and C4 did not have the Notification of Parents' Rights (LIC 995A) available for review. Based on the personnel record review, the Licensee and Licensee's Assistant/Staff (S1) did not have a current Mandated Reporter Training (AB 1207) available for review.

Based on Licensee's record review, Licensee has proof of immunization against measles, pertussis, and a TB clearance. Licensee has a decline declaration statement available for influenza. Licensee has a current Pediatric First Aid and CPR certification (expires June 2023). Licensee completed the Preventative Health and Safety Practices (EMSA-approved) training on March 24, 2018 and Mandated Reporter Training (AB 1207) on January 9, 2020. Licensee was advised that the Mandated Reporter training (AB 1207) must be completed every 2 years and is available at www.mandatedreporterca.com.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique AyalaTELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997
VISIT DATE: 01/26/2023
NARRATIVE
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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-and-resources/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 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 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

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PINs), Program Quarterly Update Newsletters and other important information communication platforms.

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 experience. If you have any questions regarding the process or tools, please send them by email 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.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique AyalaTELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 8
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997
VISIT DATE: 01/26/2023
NARRATIVE
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Deficiencies were cited during today's inspection (refer to deficiency pages).

A Notice of Site Visit (LIC 9213) was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with Licensee, Leslie Chim.
SUPERVISOR'S NAME: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique AyalaTELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/26/2023 11:40 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above as the Licensee did not have verification of the fire drills and disaster drills available for review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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Licensee will conduct a fire drill and disaster drill, and submit proof of completion to LPA via e-mail by 02/27/2023.

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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique AyalaTELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 5 of 8


Document Has Been Signed on 01/26/2023 11:40 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023

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 record review, the licensee did not comply with the section cited above in 2 out of 2 personnel records (Licensee and Licensee's Assistant/Staff (S1)) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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Personnel will complete the required Mandated Reporter Training for Child Care Providers (AB 1207), and the Licensee will submit proof of completion to LPA via e-mail by 02/27/2023.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 in 1 out of 1 children's records (C3) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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Licensee will obtain a copy of child's (C3) immunization record and submit proof of completion to LPA via e-mail by 02/27/2023.
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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique AyalaTELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 6 of 8


Document Has Been Signed on 01/26/2023 11:40 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 in 1 out of 1 children's records (C1) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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Licensee will obtain a completed Consent for Emergency Medical Treatment (LIC 627) for child (C1), and submit proof of completion to LPA via e-mail by 02/27/2023.
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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique AyalaTELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 7 of 8


Document Has Been Signed on 01/26/2023 11:40 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 CENTER DR 200B
MONTEREY PARK, CA 91754


FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

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 in 1 out of 1 children's records (C4) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/27/2023
Plan of Correction
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Licensee will obtain a completed Notification of Parents' Rights (LIC 995A) for child (C4), and submit proof of completion to LPA via e-mail by 02/27/2023.

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: Valarie CookTELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Monique AyalaTELEPHONE: (323) 246-2016
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
Page: 8 of 8