198020442-11-7-2019-33-CC-JHUA-BHPQCT-20191107110339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020442
Report Date: 11/07/2019
Date Signed: 11/07/2019 11:03:54 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:	NAHM FAMILY CHILD CARE		FACILITY NUMBER:	198020442
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	11/07/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Seo Jin Nahm		TIME COMPLETED:	11:15 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	Licensing Program Analyst (LPA) Jennifer Hua conducted a pre-licensing inspection today. LPA met with Seo Jin Nahm, Applicant who guided analyst on a tour of the facility. There are a total of 4 adults and 1 minor residing in the home. The applicant is requesting a large family child care home license. Per applicant operation hours will be Monday to Friday, 7:30 a.m. to 6:00 p.m. All areas identified on the facility sketch were inspected. This is a two-story home. There are 2 bedrooms, and 2 bathrooms on the lower level, living room, family room, kitchen, fenced back yard. Applicant will submit a floor plan sketch reflecting second level. Areas that are accessible to children are as follows: Living room, family room, bathroom in the living room, fenced side yard. LPA observed safety gate in place at kitchen entrance to make the kitchen inaccessible to the children. Children will walk from family room to the outdoors. Areas off limits to children and parents include: Entire second level, there is no access to the second level from the inside of the home, 2 bedrooms, 1 bathroom, kitchen, front yard and fenced backyard, garage and storage. Rooms that are off-limits need to be made inaccessible during operating hours Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating (central). Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible. The applicant states that there are no poison in the home, but does understand that if any poison is purchased, it is required to be locked with a key or combination lock. Applicant was advised that if food is brought from the children’s homes, all containers must be labeled with child’s name and properly stored or refrigerated.

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer Hua	TELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019

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 4

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: NAHM FAMILY CHILD CARE	FACILITY NUMBER: 198020442
	VISIT DATE: 11/07/2019

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

LPA reviewed and issued the LIC 311 - Forms/Records to Keep in Your Family Child Care Home. The following required forms were explained and provided to the applicant during this visit.

Children’s Forms/Records:
Parent Notification Additional Children in Care (LIC 9150); Affidavit Regarding Liability Insurance (LIC 282); Consent For Emergency Medical Treatment (LIC 627); Consent/Verification for Nebulizer (LIC 9166); Identification and Emergency Information (LIC 700); Notification of Parents’ Rights (LIC 995A); Caregiver Background Check Process (LIC 995E); Family Child Care Awareness Information (LIC 9212); California School Immunization Record (PM 286); Acknowledgement of Receipt of Licensing Report (LIC 9224).

Facility Forms/Records:
Proof of current Pediatric first aid and CPR must be available at all times; Unusual Incident/Injury Report (LIC 624B); Memo dated 07/11/2003 – Reporting Requirements for FCC Home Licensees; Child Care Roster (LIC 9040); Property Owner/Landlord Consent Form (LIC 9149); A copy of your Control of Property should be readily available.

Information Required to be Posted in Your Family Child Care Home
Facility License; Notification of Parents’ Rights Poster (PUB 394); Emergency Disaster Plan (where readily available in case of an emergency; Earthquake Preparedness Checklist (LIC 9148) – attach to Emergency Disaster Plan; Once licensed – Notice of Site Visit must be posted for 30 days and any report documenting a Type A violation must be posted.

Staff Forms/Records - any assistant present must have the following on file: 1) Proof of TB clearance (within one year); 2) Notice of Employee Rights (LIC 9052); 3) Criminal Record Statement (LIC 508); 4) Statement Acknowledging Requirements to Report Suspected Child Abuse (LIC 9108).

Applicant has been advised of the following:
· 101217 (g)(9)(A)(1) - Fire and earthquake drills must to be conducted and documented every six months. Documentation must be readily available
· Any assistant left alone with children must have proof of current pediatric first aid and CPR on file (AB 1368).

*REPORT CONTINUES ON NEXT PAGE

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer Hua	TELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: NAHM FAMILY CHILD CARE	FACILITY NUMBER: 198020442
	VISIT DATE: 11/07/2019

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

Per applicant, there are no dual licenses at this address.

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

The applicant will be approved for a large family child care license once all corrections are received:

1. Submit revised application (LIC279B) to reflect all adults living in the home
2. Submit current T.B. test (within 12 months) for the 2 other adults living in the home
3. Submit LIC 508 Criminal Record Statement for the 2 other adults living in the home
4. Submit LIC 9182 Criminal Background Clearance Transfer Request for the 2 other adults living in the home
5. Install carbon monoxide detector
6. Submit Floor Plan and Outdoor Sketch to reflect the accuracy of the home., including the second level.

Per applicant, will submit all corrections by 11/25/19. Applicant will contact LPA to schedule follow up inspection.

Fire clearance has been approved.

Once licensed, the applicant is required to adhere to the terms and limitation as stated on the license.

Exit interview was conducted with applicant. Applicant who is in agreement with the above. A copy of this report and all other Licensing reports must be made available to the public for 3 years.

*END OF REPORT

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer Hua	TELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019

LIC809 (FAS) - (06/04)

Page: 4 of 4

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: NAHM FAMILY CHILD CARE	FACILITY NUMBER: 198020442
	VISIT DATE: 11/07/2019

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

Applicant has completed the Health and Safety Training, pediatric CPR and First Aid training as indicated on the certificate. Pediatric First Aid and CPR will expire on 01/28/21. There are first aid supplies on the premises. Applicant has completed the Mandated Reporter Training, certificate is dated 10/15/19.
The Applicant did submit proof of required immunizations.

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

The following was discussed: Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

If an individual has already obtained a criminal record clearance with the Department, the criminal record clearance may be transferred. A Criminal Background Clearance Transfer Request form - LIC 9182 must be submitted to transfer any criminal record clearances. Prior to submitting this form, you must call our office to verify that the individual has an active criminal record clearance.

No smoking, No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.

The following was also discussed: CHILDREN’S FORMS/RECORDS, FACILITY FORMS/RECORDS and INFORMATION TO BE POSTED, Disaster drills, posting requirements, children records requirements, mandated child abuse and injury/ death reporting, criminal record transfer requirements, criminal record and child abuse clearances.

*REPORT CONTINUES ON NEXT PAGE

SUPERVISOR'S NAME: Ana Chico	TELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer Hua	TELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2019

LIC809 (FAS) - (06/04)

Page: 2 of 4