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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312126
Report Date: 01/09/2020
Date Signed: 01/09/2020 02:25:40 PM

COMPREHENSIVE INSPECTION
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:KIM, MI SUNFACILITY NUMBER:
304312126
ADMINISTRATOR:KIM, MU SUNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 651-1254
CITY:IRVINESTATE: CAZIP CODE:
92606
CAPACITY:14CENSUS: 13DATE:
01/09/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mi Sun KimTIME COMPLETED:
02:30 PM
NARRATIVE
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An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Dean Valencia. LPA observed licensee caring for 13 children; of which 3 are infants (birth through and up to 2 years old). Of the 13 children in care, none are enrolled in and attending Kindergarten, per ratio regulations. Licensee was operating within the licensed capacity as specified on license. An adult resident of the home, was present providing care along with the licensee. A review of the Facility Personnel Report Summary on this date indicates that not all individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. A resident in the home had been residing in the home without a clearance, for one day. Currently there are 3 adults residing in the home.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of baby gates and door locks. There is at least one working carbon monoxide, smoke detector, and fire extinguisher 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. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspection. The fireplace is inaccessible and not used while children are in care. The home has age appropriate toys and they are in good repair. The children use the backyard as an outdoor play area. The play area appeared safe and no hazards were observed. The play area was observed to be fully fenced and play equipment is age appropriate and in good repair. There are no bodies of water on the premises. The licensee has a current roster of children in care. Records of children present during LPA’s inspection were reviewed, and found to be out of compliance. The licensee has current Pediatric CPR/First Aid certification, expiring 12/13/2020. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. Proof of immunization against pertussis, measles for employees/volunteers were reviewed and within compliance. (Continued on LIC809C, Page 2)
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020
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 4
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: KIM, MI SUN
FACILITY NUMBER: 304312126
VISIT DATE: 01/09/2020
NARRATIVE
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(Page 2) 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 needing to complete this requirement. 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.htmThe licensee understands children are never to be left in parked vehicles and if licensee is temporarily absent from the facility, arrangements must be made for an assistant to supervise children. The substitute assistant must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. CCLD website www.ccld.ca.gov 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. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided: English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf 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:

Due to the Type A violations cited today, the licensee shall post, and provide copies, of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. The Licensee was provided a copy of 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 Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: KIM, MI SUN
FACILITY NUMBER: 304312126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2020
Section Cited

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department
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Based on a record review by LPA it was observed that the facility was not within compliance of the above regulation. This was evidenced by: an adult assistant and resident of the home, Binna Kim, did not have a criminal record clearance, for one day. This is an immediate threat to the children's health and safety.
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Type A
01/09/2020
Section Cited

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A large family day care home may provide care for more than 12 children and up to and including 14 children, if all of the following conditions are met: (a) At least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age.
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Based on a record review by LPA it was observed that the facility was not within compliance of the above regulation. This was evidenced by: The child record review showed that two children in care were 4.5, but not enrolled in nor attending kindergarten, placing the facility out of complaince with ratio. This is an immediate threat to the children's health and safety.
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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: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: KIM, MI SUN
FACILITY NUMBER: 304312126
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/23/2020
Section Cited

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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.

Based on a child records review, it was observed by LPA that the facility was not
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within compliance of the above regulation as evidenced by: 8 of the 13 child files reviewed, child #6-13, did not have any immunization records available to review. This is a potential threat to the children's health and safety.
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Type B
01/23/2020
Section Cited

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The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A.

Based on a child records review, it was
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observed by LPA that the facility was not within compliance of the above regulation as evidenced by: 11 of the 13 child files reviewed, child #2-4, 6-13, did not have the Parent's Rights Acnowledgement form signed, available to review. This is a potential threat to the children's health and safety.
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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: Dean ValenciaTELEPHONE: (714) 215-6737
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4