304206891-3-13-2024-06-CC-AFCN-D3BN9A-20240313101537

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304206891
Report Date: 03/12/2024
Date Signed: 03/13/2024 10:15:51 AM

Document Has Been Signed on 03/13/2024 10:15 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	KEUM, MARY		FACILITY NUMBER:	304206891
ADMINISTRATOR:	KEUM, MARY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 525-7870
CITY:	FULLERTON	STATE: CA	ZIP CODE:	92833
CAPACITY:	14	CENSUS: 11	DATE:	03/12/2024
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	License Mary Keum		TIME COMPLETED:	04:50 PM

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	On 03/12/24 an unannounced 3-year inspection was conducted at the facility by Licensing Program Analyst (LPA) Anna Chan. At 2:40pm LPA observed licensee, Mary Keum, caring for 11 children without assistant. Assistant arrived at 2:54pm. Licensee was not operating within the licensed capacity as specified on license. Some children were napping and some children were awake when LPA arrived. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults including the licensee and no minor child living in the facility. Facility Day care hours are 8:00am-6:00pm, Monday through Friday. During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. This is a single-story home which consists of three bedrooms, two bathrooms, living room, den (converted to playroom), kitchen, garage, front yard (not fenced), and back yard (fenced). Licensee stated that OFF LIMITS areas include: the bedrooms, garage and kitchen. Licensee acknowledged that children may never enter these off-limit areas. The areas the licensee has designated for the day care children included the living room, den, and one bathroom. The facility has conducted an emergency drill within the past six months on 2/29/24. There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. Licensee stated there no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. Page 1

SUPERVISOR'S NAME: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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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Document Has Been Signed on 03/13/2024 10:15 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEUM, MARY	FACILITY NUMBER: 304206891
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102416.5(e)

Staffing Ratio and Capacity

(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above, when LPA arrived at 2:40pm some children are napping and some are awake, and only the licensee is at the facility. The assistant arrived 15 minutes later which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/13/2024
	Plan of Correction
1 2 3 4	The licensee stated she will hire a full time assistant or will make sure her husband is in the facility when there are more than 8 children in care. Licensee stated she will send LPA a document stating that she will make sure there is an assistant with her at all times when there are more than 8 children

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEUM, MARY	FACILITY NUMBER: 304206891
	VISIT DATE: 03/12/2024

NARRATIVE

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There is no fireplace in the facility. The home has age-appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service), licensee was reminded that childcare phone needs to remain the in the childcare at all times. There are no bodies of water on the premises, and none was observed during the inspection.

The licensee does have a current roster of children in care. 5 Child’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance. Licensee stated there are no infants enrolled and none was observed during the visit.

The licensee’s Pediatric CPR/First Aid certification expires on 10/2024. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. The licensee is exempt from this requirement due to the training not being available in Korean.

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

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SUPERVISOR'S NAME: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEUM, MARY	FACILITY NUMBER: 304206891
	VISIT DATE: 03/12/2024

NARRATIVE

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The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Type A for Staffing Ratio and Capacity 102416.5(e) (see LIC 809D).

LPA Chan informed licensee Mary Keum that this report dated 03/12/24 document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Chan informed the licensee Mary Keum to provide a copy of this licensing report dated 03/12/24 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.
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SUPERVISOR'S NAME: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEUM, MARY	FACILITY NUMBER: 304206891
	VISIT DATE: 03/12/2024

NARRATIVE

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Licensee, Mary Keum was reminded that all adults 18 and over living or working in the home, 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.

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/process.

Exit interview conducted and report was reviewed with the licensee Mary Keum. A notice of site visit was given and must remain posted for 30 days.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 03/22) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
End of Report.

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SUPERVISOR'S NAME: Martha Malane	TELEPHONE: (310) 740-3022
LICENSING EVALUATOR NAME: Anna Francesca Chan	TELEPHONE: (818) 216-9775
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

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