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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313054
Report Date: 09/17/2019
Date Signed: 09/17/2019 03:35:22 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:MOON, SUN WONFACILITY NUMBER:
304313054
ADMINISTRATOR:MOON, SUN WONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 342-8095
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:14CENSUS: 12DATE:
09/17/2019
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Sun Won Moon - LicenseeTIME COMPLETED:
04:05 PM
NARRATIVE
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An unannounced random/annual inspection was conducted today by Licensing Program Analyst (LPA) Gigi Mai. Met with licensee, Sun Won Moon, and 2 assistants. Licensee guided analyst on a tour of the Early Childhood Setting. Present at the time of the inspection were 12 day care children, 11 preschoolers and 1 infant. There are presently 2 adults living in the home. A review of adult records indicates that all facility residents, staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The home was toured inside and outside, licensee was operating within the licensed capacity. Operating hours are 8:00AM to 6:00PM, Monday through Friday. Licensee stated that OFF LIMITS areas are: entire upstairs, kitchen and garage. Licensee has placed a baby gate at bottom of the stairs. Licensee acknowledged that children may never enter these off-limit areas. Cleaning solutions/chemicals, sharp utensils, and sharp knives are all inaccessible. Licensee stated poisons/hazardous items are not kept on the premises. License understands that cleaning solutions/chemicals must be made inaccessible to children at all times and poisonous items must be key/combo locked at all times.

Fire extinguisher (2A:10BC) observed to be fully charged, smoke detectors and carbon monoxide detector were present and tested during inspection. Children's files and current roster were reviewed on today's inspection. Licensee did not have a fire and disaster drill log. The licensee has a cell phone that is used for child care. The licensee was reminded that if a cell phone is used, it must remain on the premises at all times during hours of operation. Licensee stated that there are no firearms on the premises and none were observed during today's visit. LPA advised anytime when firearms are present, they must be locked and stored separately from the ammunition.

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SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Gigi MaiTELEPHONE: (714) 743-8565
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2019
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 5
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: MOON, SUN WON
FACILITY NUMBER: 304313054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2019
Section Cited

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102417(g)(9)(A)(1) Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months and document the date and time of each drill. This requirement was not met as evidenced by:
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Based on observation and interview, licensee failed to conduct a fire and disaster drill at least once every six months, and failed to maintain a log to document the date and time of each drill. This poses a potential health and safety to 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: Gigi MaiTELEPHONE: (714) 743-8565
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
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: MOON, SUN WON
FACILITY NUMBER: 304313054
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2019
Section Cited

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Effective September 1, 2016, a person may not be employed or volunteer at a child care center or a family child care home unless he or she has been immunized against influenza, pertussis, and measles or qualifies for an exemption...This requirement was not met as evidenced by:
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Based on record review and interview, Licensee failed to obtain proof of immunizations/immunity against measles and pertussis for Staff #2. This poses a potential health risk to children in care.
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Type B
09/30/2019
Section Cited

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On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training…This requirement is not met as evidenced by:
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Based on record review and interview, Proof of completion of required mandated reporter training was not available for review during today's inspection for licensee and 2 staff. This poses a potential health and safety risk to 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: Gigi MaiTELEPHONE: (714) 743-8565
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2019
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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: MOON, SUN WON
FACILITY NUMBER: 304313054
VISIT DATE: 09/17/2019
NARRATIVE
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A Child Care Provider’s Guide to Safe Sleep packet, Safety Seat, Never Ever Shake a Baby information, California Child Passenger Safety Law were discussed and recommended to be posted. Safe Sleep Regulation and Effects of Lead Exposure were discussed and provided to the licensee. The licensee was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

The following electronic links were also provided:


SIDS: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
The Chaptered Legislation for AB 2084 (Nutritious Beverages) http://ccld.ca.gov/res/pdf/12APX-11.pdf

In the areas that were evaluated, the following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: HSC 1597.622, HSC 1596.8662(b)(1) and 102417(g)(9)(A)(1).

The Notice of Site Visit was posted. 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. Exit interview was conducted. Appeal Rights were discussed. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeals should be sent to the regional manager to the address listed above. All appeals must be in writing and received by the Licensing office within 15 business days. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.


Page 3 of 3. [End of Report]

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Gigi MaiTELEPHONE: (714) 743-8565
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: MOON, SUN WON
FACILITY NUMBER: 304313054
VISIT DATE: 09/17/2019
NARRATIVE
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There are age appropriate toys and napping equipment on the premises for the potential ages served. The licensee stated she is present in the home and ensures that the children in care are supervised at all times. The licensee stated children are not left in parked vehicles. The licensee states when temporarily absent from the home, she arranges for a substitute adult to care for and supervise children in her absence. No smoking, No infant walkers, No Johnny jumpers, No exersaucer or any other similar items that fall into that category are allowed in the facility.

LPA observed pediatric CPR/First Aid certification (expires 01/23/2020) they are EMSA approved and curren for the licensee and one assistant. Proof of immunization against influenza (or written decline) pertussis and measles for licensee and assistants were reviewed and not within compliance of SB 792, Staff #2 did not have proof of immunizations on file. Licensee and both staff have not completed the mandated reporter training certificate as required.

Incidental Medical Services (IMS) policy was discussed, licensee stated she does not plan to provide it at this time. 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 licensing office within 30 days of providing IMS. The plan should describe the facility’s policies and procedures that ensure the proper safeguards are in place. 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

LPA reviewed Unusual Incident Report form and advised the applicant to contact Licensing Officer of the Day within 24 hours by phone or fax and complete the Unusual Incident Report (LIC 624B) within seven days. LPA reviewed with the licensee of Title 22 regulations, requirements of disaster drills, LIC 311D posting requirements, children’s records, facility/staff records, immunizations, mandated child abuse and injury/death reporting.

Page 2 of 3.

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Gigi MaiTELEPHONE: (714) 743-8565
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5