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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198020442
Report Date: 12/04/2019
Date Signed: 12/04/2019 01:03:12 PM

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 CAREFACILITY NUMBER:
198020442
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 2DATE:
12/04/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:14 PM
MET WITH:Seo Jin NahmTIME COMPLETED:
01:10 PM
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Follow up prelicensing inspection conducted by Licensing Program Analyst, Jennifer Hua. LPA met with applicant, Seo Jin Nahm. The purpose of the follow up inspection is to ensure all corrections noted on licensing report dated 11/7/19 are complete.

LPA received the revised application to reflect all adults living in the home
LPA received the current T.B. test for all adults living in the home
LPA received LIC 508 Criminal Record Statement for all adults in the home
LPA received LIC 9182 Criminal Background Clearance transfer Request for the 2 adults living in the home
LPA observed a carbon monoxide detector in the home located in the family room
LPA received the revised Floor Plan and Outdoor sketch to reflect the accuracy of the home, including the second level.

Based on observations today, facility is ready to be licensed.

An exit interview conducted with applicant, copy of the report
SUPERVISOR'S NAME: Ana ChicoTELEPHONE: (323) 513-3793
LICENSING EVALUATOR NAME: Jennifer HuaTELEPHONE: (323) 981-3375
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2019
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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