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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313649
Report Date: 08/23/2019
Date Signed: 08/23/2019 01:22:51 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:LEE, SORAFACILITY NUMBER:
304313649
ADMINISTRATOR:LEE, SORAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(657) 255-4567
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:14CENSUS: 0DATE:
08/23/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Sora LeeTIME COMPLETED:
01:35 PM
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Licensing Program Analysts (LPA), Stacy Torrence conducted an announced Pre-Licensing inspection of the home on today's date. LPA Torrence toured the Early Childhood Setting indoors and outdoors with applicant, Sora Lee. The applicant has requested a license for a large family child care home with operating hours of Monday through Friday 8:00 AM to 6:00 PM. A review of adults' records on today's date indicates that all adults live in the home or individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The facility is a single-family home with four bedrooms, three bathrooms, living room, dining room, kitchen, attached garage, covered porch, front yard (not fenced), and fenced backyard. The home was clean, orderly, and was at a comfortable temperature. There is a fireplace in the home, which is located behind a built wall, inaccessible to children in care. Off limits areas are: three bedrooms, two bathrooms (applicant has placed a lock at the top of each door; ensuring areas are inaccessible to the children in care), kitchen and dining room (two doors leading to the kitchen and dining room have child safety knobs), laundry room (safety latches on doors), and attached garage(locked). The applicant acknowledged the children may never enter the off-limit areas. Per applicant, daycare rooms are the following: living room, covered porch, one bedroom, and one bathroom (located in the hallway).

Cleaning solutions/chemicals, utensils, and sharp knives are all inaccessible. Applicant stated there are no poisons/hazardous items located in the home.

There are age appropriate toys, learning material, and napping equipment on the premises for the potential ages served. There are no bodies of water on the premises. The applicant stated that there are no firearms on the premises. LPA advised anytime when firearms are present, they must be locked and stored separately from the ammunition. Fire extinguisher (2A:10-BC) observed to be fully charged, a smoke detector and carbon monoxide detector were present and were functioning during today's inspection.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
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 3
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: LEE, SORA
FACILITY NUMBER: 304313649
VISIT DATE: 08/23/2019
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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

A Child Care Provider’s Guide to Safe Sleep packet, Safety Seat, Never Ever Shake a Baby information, Safe Sleep Regulation, and Effects of Lead Exposure were discussed and provided to the applicant. 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 applicant was also informed to visit the http://ccld.ca.gov website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

The applicant was provided a copy of their appeal rights (LIC9058 12/15) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional manager, address is above on the report. The licensee was informed of how/where to access regulations and forms from CCLD website:
www.ccld.ca.gov.

This facility meets licensing requirements on this date and a license for a large family child care home will be issued pending a final review. An exit interview conducted where the report was discussed and provided to the applicant.



– END OF REPORT –
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: LEE, SORA
FACILITY NUMBER: 304313649
VISIT DATE: 08/23/2019
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LPA reviewed the 16 hours Preventative Health, Pediatric CPR/First Aid certification (exp. 11/2020), and they are EMSA approved and current for the applicant. Current immunization information for pertussis, measles, influenza, and mandated reporter training were verified by LPA. Control of property was verified by LPA during today's inspection. Applicant has provided LPA with a Declaration (LIC 855) explaining that her name is not on the mortgage bill; however, has provided the LPA with a copy of her marriage license and a current Southern California Gas bill with her name on it.

The LPA advised the applicant to contact licensing for any changes of off limit areas, operation hours or change in phone number. Applicant provided LPA with her email address. The applicant has a landline and cell phone that is used for child care. The applicant was reminded that if a cell phone is used, it must remain on the premises at all times during hours of operation. In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations as required by SB 792 (pertussis, measles, and influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.

The following were discussed: Individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to being present in the facility. Individuals within one month of their 18th birthday must be fingerprinted immediately. If adult is fingerprinted cleared and associated to another facility, licensee must complete a Criminal Record Clearances or Exemption Transfer Request form (LIC 9182 or LIC 9188) with copy of ID and Criminal Record Statement (LIC 508) and fax to (714)703-2831 prior to hiring adult. Civil Penalties will be assessed if not in compliance.

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 applicant of Title 22 regulations, requirements of disaster drills (documented every 6 months), LIC 311D posting requirements, children’s records, facility/staff records, mandated child abuse and injury/death reporting. LPA explained to the applicant of children's rights, including no intimidation, humiliation, and no corporal punishment. The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.

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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3