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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400037
Report Date: 07/01/2024
Date Signed: 07/02/2024 10:53:48 AM


Document Has Been Signed on 07/02/2024 10:53 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754



FACILITY NAME:KOREAN BAPTIST CHURCH SCHOOLFACILITY NUMBER:
198400037
ADMINISTRATOR:AMY HYEMI OHFACILITY TYPE:
850
ADDRESS:964 SOUTH BERENDO STTELEPHONE:
(213) 793-3311
CITY:LOS ANGELESSTATE: CAZIP CODE:
90006
CAPACITY:150CENSUS: 47DATE:
07/01/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Kyoung Back TIME COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Seung Lee conducted an unannounced case management inspection. Upon arrival LPA Lee met with office manager Kyoung Back who provided a tour of the facility.

The purpose of the inspection today was to verify information regarding an incident report provided by the facility on 06/28/2024. During this inspection, LPA Lee conducted interviews, reviewed documents, and made observations in regards to the incident.

During the inspection LPA Lee observed that Child#1 fell while the classroom was lining up to go to a different classroom. According to the facility the child fell hit their head on the door area of the classroom.

Based on the information verified during this inspection, LPA Lee did not observe any type of deficiencies at this time.

The notice of site inspection must remain posted for a period of 30 days during hours of operation. Failure to maintain posting will result in a civil penalty of $100.00 dollars.

Exit interview conducted with Director Kyoung Back. Appeal rights discussed and explained.
SUPERVISOR'S NAME: Christina GabelmanTELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Seung LeeTELEPHONE: (323) 981-3382
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2024
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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