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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415417
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:05:39 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KEEUMFACILITY NUMBER:
434415417
ADMINISTRATOR:HEE SUNG KIMFACILITY TYPE:
850
ADDRESS:2478 WEST EL CAMINO REALTELEPHONE:
(650) 646-1341
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY:42CENSUS: 30DATE:
07/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Hee Sung KimTIME COMPLETED:
02:20 PM
NARRATIVE
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On 7/29/21 at 10:18am, Licensing Program Analyst (LPA) B. Plumboy met with Director Hee Sung Kim for another purpose which resulted in a case management inspection. Present for this inspection was 7 fingerprint clear and associated staff as well as 30 children in care. At 12:34pm, LPA Plumboy observed a roach present at the facility.
See 809-D for deficiency cited today. A notice of site visit was given and must remain posted for 30 days. Appeal Rights were given and discussed. An exit interview was conducted.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KEEUM
FACILITY NUMBER: 434415417
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2021
Section Cited

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101238(a)(1) Buildings and Grounds. The licensee shall take measures to keep the center free of flies, other insects and rodents.
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This requirement was not met as evidenced by:
Based on observation, at 12:34pm LPA Plumboy observed a roach in the facility and informed the center director. Insects in the facility poses a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana PlumboyTELEPHONE: (510) 725-7005
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021
LIC809 (FAS) - (06/04)
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