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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312478
Report Date: 06/19/2019
Date Signed: 06/19/2019 04:26:21 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:KIM, AE RYONFACILITY NUMBER:
304312478
ADMINISTRATOR:KIM, AE RYON & KIM, DAVIDFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 741-5240
CITY:LA PALMASTATE: CAZIP CODE:
90623
CAPACITY:14CENSUS: 8DATE:
06/19/2019
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kim, Ae RyonTIME COMPLETED:
01:45 PM
NARRATIVE
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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, Ae Ryon Kim and a census taken. Observed was licensee, spouse, adult child, eight children, one who were under the age of two. 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 LPA toured the facility inside and outside. Medication storage, 1st aid kit, and cleaning supplies storage were inspected. Facility met all posting requirement. The facility clean and in good repair, hazards inaccessible or locked, fire place screened. 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. Licensee stated off limit areas include: bedroom that is on the left as one enters the hallway, a bedroom that is on the right as one enters the hallway, a bedroom that is before as one enters the hallway, and attached garage.
Facility files were reviewed, including liability insurance for family child care home, facility roster, and fire and disaster drill log. Licensee, staff#1, and staff#2 records were not able to review upon request: including, TB test, immunization records (Measles, Pertussis, and Influenza), Criminal Record Statement, and Mandated Reporter Training Certificates. Staff#3 records were available to review except immunization records and Mandated Reporter Training Certificates. Licensee and staff#1’s primary language is not English. The licensee and staff#1 do not need to provide Mandated reporter training certificate. Staff#2 and staff#3 needs to complete mandated reporter training certificate every two years and maintain in the staff file. Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years, per A.B. 1207.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2019
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: KIM, AE RYON
FACILITY NUMBER: 304312478
VISIT DATE: 06/19/2019
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 HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
LIC809 (FAS) - (06/04)
Page: 2 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: KIM, AE RYON
FACILITY NUMBER: 304312478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Facility Administration - Administration of Child Day Care Licensing
(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
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Based on record review and interview, the licensee failed to ensure to conduct mandated reporter training and obtain certificates for all staff at the facility. This poses a potential Safety risk to the children in care.
POC Due Date: 07/19/2019
Plan of Correction
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The licensee will submit proof by email by due date.
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
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Based on record review and interview, the licensee failed to ensure to update children's immunization records on Blue card (PM 286).
POC Due Date: 07/19/2019
Plan of Correction
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The licensee will submit all 8 children's updated blue card 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 HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2019
LIC809 (FAS) - (06/04)
Page: 3 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: KIM, AE RYON
FACILITY NUMBER: 304312478
VISIT DATE: 06/19/2019
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,
Licensee is current with Pediatric CPR and First Aid and both valid until 4/2021. 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 not provide Incident Medical Services.
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

Based on LPAs observations ,record reviews, and interviews the following violations were observed are being cited in accordance with California Code of Regulations, Title 22, Division 12, Section 102418(g)(1), 102369 (b)(9), 102416.1 (a)(11), 102417 (r) 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 HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2019
LIC809 (FAS) - (06/04)
Page: 4 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: KIM, AE RYON
FACILITY NUMBER: 304312478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
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Based on record review and interview, the licensee failed to ensure to maintain immunization records (Pertussis and Measles vaccine) for staff#1, staff#2, staff#3, and staff#4. This poses a potential Health and Safety risk to the children in care.
POC Due Date: 07/19/2019
Plan of Correction
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The licensee will submit proof by email by due date.

JUNGMI.HAN@DSS.CA.GOV
Type B
Section Cited
CCR
102369(b)(9)
Facility Administration
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
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Based on record review and interview, the licensee failed to ensure to maintain TB test record for staff#1, staff#2, and staff#4. This poses a potential Health and Safety risk to the children in care.
POC Due Date: 07/19/2019
Plan of Correction
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Licensee will submit proof by email by 7/19/2019.

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 HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2019
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: KIM, AE RYON
FACILITY NUMBER: 304312478
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2019

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.1(a)(11)
Facility Administration
102416.1(a)(11) Personnel Records (11) A signed statement regarding their criminal record history as required by Section 102370(c)
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee failed to ensure to maintain criminal record statement (LIC 508) for staff#1, staff#2, and staff#4. This poses a potential Safety risk to the children in care.
POC Due Date: 07/19/2019
Plan of Correction
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The licensee will submit proof by email by due date.
Type B
Section Cited
CCR
102417(r)
Facility Administration
102417( r) Operation of a Family Child Care Home (r) A signed and dated copy of LIC 9052 (Rev. 4/88), Notice of Employee Rights, shall be maintained in the employee's personnel record.
Deficient Practice Statement
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Based on record review and interview, the licensee failed to ensure to maintain Employee Right (LIC 9152) for staff#1 and staff#2. This poses a potential Health and Safety risk to the children in care.
POC Due Date: 07/19/2019
Plan of Correction
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The licensee will submit proof by email by due date.

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 HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2019
LIC809 (FAS) - (06/04)
Page: 6 of 6