304300227-6-17-2019-06-CC-JMHN-BD8JJ7-20190617070505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304300227
Report Date: 06/14/2019
Date Signed: 06/17/2019 07:05:19 AM

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:	SUH, OLIVIA		FACILITY NUMBER:	304300227
ADMINISTRATOR:	SUH, OLIVIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 562-8800
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	14	CENSUS: 8	DATE:	06/14/2019
TYPE OF VISIT:	Required - 3 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Olivia Suh		TIME COMPLETED:	05:30 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	The annual/random inspection conducted in Korean. Licensing Program Analyst (LPA), Han conducted an unannounced annual/random inspection of the facility on today's date. LPA Han toured the facility with the licensee, Olivia Suh and a census taken. Observed was licensee, spouse, eight children, three who were under the age of two. Children were napped during the inspection. A review of staff criminal clearance records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The home has an in ground pool in the backyard area with fencing and self-latching gate that meets regulations. LPA advised that she must check the backyard area and close the pool gate and all other off limit areas before operation hours. Additionally, the licensee stated she does not use the pool while children in care. The LPA toured the facility inside and outside. Medication storage, 1^st aid kit, and cleaning supplies storage were inspected. Facility met all posting requirement. The facility clean and in good repair, hazards inaccessible or locked, stairs barricaded, fire place screened, bodies of water inaccessible. There are age appropriate toys and equipment on the premises. The required fire extinguisher (2A10BC), carbon monoxide, and smoke detectors are in operable condition. Per Licensee there are no weapons in the facility at this time. The licensee has designated the bedroom that is at the end of the hallway, bathroom that is on left side as one enters the hallway, and backyard are used for childcare. Facility files were reviewed, including facility roster. Fire and disaster drill log was not available to review. Licensee and spouse records were reviewed, including Criminal Record Statement and current CPR and First Aid. TB test for three adults at the facility, immunization records (Measles, Pertussis, and Influenza) and Mandated Reporter Training Certificates for for licensee and spouse were not available to review at the time of the facility inspection.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019

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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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: SUH, OLIVIA	FACILITY NUMBER: 304300227
	VISIT DATE: 06/14/2019

NARRATIVE

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No smoking on premises, infant walkers, bouncers, Johnny jumpers, exersaucer or any other similar items that fall into that category are allowed in the facility.

An exit interview was completed. The report was reviewed and discussed. Appeal Rights and deficiencies were discussed. The facility representative was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Licensing office within 15 business days.
Any proposed changes to the physical plant, including telephone number, shall be immediately reported to the Department.
The facility representative was informed that the “Notice of Site Visit” must be posted for 30 consecutive days. Failure to post will result in Civil Penalties of $100.00. The “Notice of Site Visit” must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SUH, OLIVIA	FACILITY NUMBER: 304300227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)(1)

Records - Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. (1) This requirement includes updating each child's PM 286 (6/95) when the child is due to receive required immunizations after enrollment in the family day care home.
	Deficient Practice Statement
1 2 3 4	Based on LPAs record review and interview, licensee failed to ensure to maintain children's immunizations on PM 286. This poses a potential Health and Safety risk to the children in care.
	POC Due Date: 07/14/2019
	Plan of Correction
1 2 3 4	Licensee will update eight children's immunization record on PM 286 and submit proof by 7/14/2019 by email. JUNGMI.HAN@DSS.CA.GOV

Type B

Section Cited

HSC

1597.622(a)(1)

Records - Family Day Care Homes

(1)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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.
	Deficient Practice Statement
1 2 3 4	Based on LPAs record review and interview, licensee failed to ensure to maintain licensee and spouse's immunizations. This poses a potential Health and Safety risk to the children in care.
	POC Due Date: 07/14/2019
	Plan of Correction
1 2 3 4	Licensee will submit proof of immunization records for both licensee and spouse by email. JUNGMI.HAN@DSS.CA.GOV

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 Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SUH, OLIVIA	FACILITY NUMBER: 304300227
	VISIT DATE: 06/14/2019

NARRATIVE

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Eight children’s records were reviewed, including, Notification of parents’ rights, Parent notification additional children in care, Parent notification additional children in care, Identification and Emergency information, Consent for emergency medical treatment, Affidavit regarding liability insurance for family child care home. All children's PM 286 has not been updated. Licensee is current with Pediatric CPR and First Aid and both valid until 3/2021. Licensee was reminded that licensee must present at facility and ensure that children are properly cared for and supervised at all times. Licensee must make sure that a substitute adult cares for the children when licensee is temporarily absent. The licensee was also reminded that no child shall be left alone in a parked vehicle at any time.
Licensee does provide Incident Medical Services.
This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

Based on LPAs record reviews and interviews the following violations were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 102417(g)(9)(A)(1), 102418 (g)(1), 102369 (b)(9) and Health and Safety 1596.8662 (b)(1), 1597.622 (a)(1). Please refer to attached 809D for documentation of deficiencies.
The following was discussed with licensee: Providers guide to Safe Sleep, Never Shake a Baby, Ratio and Capacity, Quarterly updates, Advocate program contact, 25 E-learning Modules, Mandated Reporter training, Criminal record clearance, Unusual Incident Report (LIC624B), AB 2084 (Nutritious Beverages), Immunization for staff, Indoor/Outdoor activity space equipment condition, Lead exposure information, California Child Passenger Safety Law, Supervision. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf. The below links offer more information on safe sleep to our providers
https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

SUPERVISOR'S NAME: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019

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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: SUH, OLIVIA	FACILITY NUMBER: 304300227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Facility Administration

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, licensee failed to ensure to maintain mandated reporter training certificates for both licensee and spouse who is assisting licensee dureing the business hours. This poses a potential Health and Safety risk to the children in care.
	POC Due Date: 07/14/2019
	Plan of Correction
1 2 3 4	Licensee will submit proof by email by 7/14/2019. JUNGMI.HAN@DSS.CA.GOV

Type B

Section Cited

CCR

102417(g)(9)(A)(1)

Facility Administration

102417(g)(9)(A)(1) Operation of a Family Child Care Home. (1)The licensee shall document the drills, including the date and time of each drill. This documentation shall be kept at the family child care home. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based record review and interview, the licensee failed to ensure to maintain fire and disaster drill log after each practice. This poses a potential Safety risk to the children in care.
	POC Due Date: 07/14/2019
	Plan of Correction
1 2 3 4	Licensee will submit proof after practice by email. JUNGMI.HAN@DSS.CA.GOV

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 Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: SUH, OLIVIA	FACILITY NUMBER: 304300227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102369(b)(9)

Records

102369(b)(9) Application for Initial License (b) The applicant shall provide all of the following information...(9) Evidence of a current tuberculosis clearance, ... for any adult in the home during the time that children are under care. This requirement is not meet as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and interview, the licensee failed to ensure to maintain tuberculosis record for all three adults at facility. This poses a potential Health and Safety risk to the children in care.
	POC Due Date: 07/14/2019
	Plan of Correction
1 2 3 4	Licensee will submit proof by email by due date. JUNGMI.HAN@DSS.CA.GOV

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: Judy Hanson	TELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi Han	TELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2019

LIC809 (FAS) - (06/04)

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