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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304204546
Report Date: 05/02/2019
Date Signed: 05/02/2019 12:29:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SONG, EUNJAFACILITY NUMBER:
304204546
ADMINISTRATOR:SONG, EUNJAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 821-4000
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:14CENSUS: 3DATE:
05/02/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Eunja Song and Young Song, LicenseeTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Yesenia Villa conducted an unannounced annual random inspection to the above facility. LPA met with Eunja Song, Licensee there were 3 children and Licensee’s husband present upon arrival. The hour of operation per Licensee are from 8am-6:00pm Monday to Friday. The inspection was conducted in English with the assistance of CTS Language Link, Operator #12007. The licensee’s primary language is Korean.

The licensee states that she currently has 7 children enrolled in the day care, 5 toddlers and 2 infants. The licensee is observed to be operating within the license capacity limitations during this visit. The children’s roster was available and is current.

This is a two story home which consists of 3 bedrooms, 2 1/2 bathrooms, downstairs room, living room, backyard and front yard. All areas identified on the facility sketch that children use, were inspected for safety, comfort, cleanliness, telephone service, central ventilation and heating is available in the home.

The following was observed and reviewed during this inspection. Per licensee the bedrooms, kitchen and upstairs restrooms are off limit areas to the children. The children utilize the back and front yard for play time. During today’s inspection of the backyard play area, LPA Villa observed children plastic swings repaired with screws, the screws are sticking up from the plastic and are accessible to the children (pictures were taken). The Licensee's spouse removed the swings during the inspection. Licensee's spouse cleaned the area during visit.

Licensee’s spouse was asked to de-clutter/clean the area and keep all areas designated for the children free of clutter.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019
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 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SONG, EUNJA
FACILITY NUMBER: 304204546
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2019
Section Cited
CCR
102417(g)(10)
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102417(g)(10) OPERATION OF A FAMILY DAY CARE HOME Operation of a Family Child Care Home. A baby walker is not permitted on the premises of a family child care home in accordance with Health...

This requirement is not met as evidence: LPA observed an exersaucer in the day
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Licensee removed the exersaucer during today's inspection. Corrected during visit.
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care room. This poses a potential risk to the safety of the children in care.
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Type B
05/09/2019
Section Cited
HSC
1597.543
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H&S 1597.543 Carbon monoxide detectors required; inspection. Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. Licensee stated she was unaware of the carbon monoxide requirement.
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Licensee will submit pictures to the Department and proof of purchase by Proof of correction date of 05/09/19.

yesenia.villa@dss.ca.gov
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This requirement was not met as evidence: Licensee did not have a carbon monoxide alarm. This poses a potential risk to the health and safety to the children in care.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019
LIC809 (FAS) - (06/04)
Page: 5 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SONG, EUNJA
FACILITY NUMBER: 304204546
VISIT DATE: 05/02/2019
NARRATIVE
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The backyard has a swimming pool that is not filled in with water, per Licensee the pool will be filled with water after repairs. LPA observed the fence requirement for bodies of water and area to meet the bodies of water regulations. Licensee’s spouse was advised to notify the department once the pool had been filled and repairs were made for another inspection.

The front yard was observed to have appropriate toys for the children. There was shade provided by the trees and cushioning material under the apparatus. Licensee was reminded that 100 percent supervision is required at all times.

Licensee states that 2 adults live in the home. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. Licensee states her spouse and daughter both assist her with the children in care. Licensee was advised that Pediatric/First Aid CPR is required for any assistant left alone with the children. The licensee and assistants all have expired Pediatric, CPR/First Aid certifications with an expiration date of 02/11/2019 and 07/20/2018.

Per Licensee, Breakfast, Lunch and snack are provided. LPA Villa observed the kitchen to be unclean and disorderly (pictures were taken). Licensee states they were in the middle of cleaning and will send pictures once they are complete with the cleaning. Detergents, cleaning compounds, medications, and other items which could pose a danger are inaccessible to children.

The valve on the required 2A 10BC fire extinguisher indicates fully charged. Per State Fire Marshall standards, fire extinguishers shall be serviced annually. Smoke alarm was observed during today’s inspection. The Licensee did not have a carbon monoxide detector present during today’s inspection.

H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SONG, EUNJA
FACILITY NUMBER: 304204546
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/09/2019
Section Cited
CCR
102416.1
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102416.1 Personnel Records
(a) Personnel records shall be maintained on each employee and shall contain the following information:

This requirement is not met as evidence by: Licensee did not have records for herself or her assistants. This poses a potential risk to the
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Licensee will submit proof of personnel records for herself and her two assistants by Proof of correction date of 05/09/19.

yesenia.villa@dss.ca.gov
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safety of the children in care.
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Type B
05/09/2019
Section Cited
CCR
102417(b)
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102417(b)- Operation of a Family Child Care home(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidence LPA observed the kitchen not orderly there was food left out on the counters with personnel
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Licensee will submit pictures to the Department by Proof of Correction date of 05/09/19.

yesenia.villa@dss.ca.gov
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items such as body creams. This poses a potential risk to the health of the children in care.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019
LIC809 (FAS) - (06/04)
Page: 6 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SONG, EUNJA
FACILITY NUMBER: 304204546
VISIT DATE: 05/02/2019
NARRATIVE
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LPA advised the licensee how to access forms, regulations and quarterly updates on line at: www.ccld.ca.gov.
Based on the LPA’s observations and records review, 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.

Exit interview was conducted with Young Song , Licensee, including, but not limited to Appeal Procedures, Site Visit and Initial Appeal Rights. A notice of site visit was posted and Licensee was informed that failure to keep for 30 days will result in a civil penalty fee of $100.00 per title 22 regulations.

Upon receipt of a report documenting a Type A deficiency or substantiated complaint, the licensee shall do the following:

1. Health and Safety Code Section 1596.8595 (c) - A licensed child care facility or home shall provide to the parents of each child receiving services in the facility copies of any licensing report that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as specified in paragraph (1) of subdivision (a) of Section 1596.893b. Failure to comply with paragraph (1) shall result in an immediate civil penalty of one hundred dollars ($100).

2. Each licensed child day care facility shall post a copy of any licensing report pertaining to the facility that documents either a facility inspection or a complaint investigation that results in a citation for a violation that, if not corrected, will create a direct and immediate risk to the health, safety, or personal rights of children in care. Failure to comply with paragraph (1) shall result in an immediate civil penalty of one hundred dollars ($100).3. Upon enrollment of a new child in a facility, the licensee shall provide to the parents or legal guardians of the newly enrolling child copies of any licensing report that the licensee has received during the prior 12-month period that documents any Type A citation that represents an immediate risk to the health, safety, or personal rights of children in care as set forth in paragraph (1) of subdivision (a) of Section 1596.893b. 4. The licensee shall require each recipient of the licensing report described to sign a statement (LIC 9224) indicating that he or she has received the document and the date it was received. The Acknowledgement form (LIC 9224) must be maintained in each child’s file immediately upon receipt from parent. A copy of the parent Acknowledgement of Receipt of Licensing Reports Form was provided during this inspection. End of report
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SONG, EUNJA
FACILITY NUMBER: 304204546
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2019
Section Cited
CCR
102416(c)
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102416 Personnel Requirements(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.
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The licensee will submit proof of updated CPR certfication to the Department by Proof of Correction date of 05/09/19.

yesenia.villa@dss.ca.gov
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This requirement was not met as evidence: Licensee and Both Assistants have expired CPR Certificates. This poses an immediate risk to the health and safety of the children in care.
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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019
LIC809 (FAS) - (06/04)
Page: 7 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SONG, EUNJA
FACILITY NUMBER: 304204546
VISIT DATE: 05/02/2019
NARRATIVE
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Personnel files was reviewed for immunization's, MMR, TDAP and Influenza. Licensee did not have a file for herself and her assistants. She was able to show proof of correction from a previous Immunization citation as proof that she submitted the corrections to the Department on 11/06/2017. LPA informed Licensee that her two assistance and herself require a personnel record with proof of immunization's and LIC forms. Mandated reporter training was discussed and due to the test not being available in Korean, Licensee and Spouse are exempt. Mandated reporter training will be required of the other assistant. Children’s records were reviewed, including but not limited to, a copy of the emergency information card that contains all the information specified by regulation. The following items were also discussed with licensee during this inspection.

LPA discussed the prohibited items at the facility such as Infant Walkers, Johnny Jumpers, Saucer Chairs, Exersaucers, Trampolines and/or any other item that falls into these categories. Licensee had an Exersaucer in the children’s playroom. Licensee removed the Exersaucer to the back yard and was reminded that such items are prohibited in the daycare.

LPA advised the licensee to sleep infants where they can always be directly supervised and advised the licensee against sleeping infants in a separate room. LPA advised infant sleeping areas should be free of any blankets, toys or pacifiers with attachments. Licensee was informed about Safe Sleep regulations and provided reading materials as follows. LPA provided the licensee with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics and Helping you to reduce the risk of SIDS.

Incidental Medical Services (IMS):
The licensee states that she will provide IMS. Per licensee, there are no children enrolled that require IMS at this time. 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.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Yesenia VillaTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2019
LIC809 (FAS) - (06/04)
Page: 4 of 7