434415417-7-29-2021-52-CC-WNOA-C5XUAG-20210816152441

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434415417
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:06:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2021 and conducted by Evaluator Briana Plumboy

COMPLAINT CONTROL NUMBER: 52-CC-20210719135423

FACILITY NAME:	KEEUM		FACILITY NUMBER:	434415417
ADMINISTRATOR:	HEE SUNG KIM		FACILITY TYPE:	850
ADDRESS:	2478 WEST EL CAMINO REAL		TELEPHONE:	(650) 646-1341
CITY:	MOUNTAIN VIEW	STATE: CA	ZIP CODE:	94040
CAPACITY:	42	CENSUS: 30	DATE:	07/29/2021
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Hee Sung Kim		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Absence of Supervison- Child left unsupervised outside the facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 7/29/21 at 10:18am, Licensing Program Analyst (LPA) B. Plumboy met with Director Hee Sung Kim for the purpose of an UNANNOUNCED COMPLAINT INSPECTION. Present for this inspection was 7 fingerprint clear and associated staff as well as 30 children in care.
The allegation C1 was outside the door on the playground without supervision has been SUBSTANTIATED. Based on LPA Plumboy's interviews, observations, and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22, Division 12, Chapter 1, Section 101229(a)(1) is being cited on the attached LIC. 9099D.
LIC 9224 was issued and discussed.
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.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 52-CC-20210719135423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A 07/30/2021 Section Cited CCR 101229(a)(1)	1 2 3 4 5 6 7	101229(a)(1) Care and Supervision. No child(ren) shall be left without the supervision, including visual observation, of a teacher at any time except as specified in sections 101216.2(e)(1) and 101230(c)(1).	1 2 3 4 5 6 7	POC: By 7/31/21, a written plan of action will be sent to Licensing detailing steps staff will take to ensure children are supervised at all times.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by interviews and record review conducted. This poses an immediate risk for the health and safety of children in care. WHILE IN CARE, A CHILD WAS LEFT OUTSIDE THE FACILITY AND OBSERVED TO BE STANDING OUTSIDE A CLOSED DOOR ON THE PLAYGROUND ALONE.	8 9 10 11 12 13 14	THIS IS A ZERO TOLERANCE VIOLATION WITH AN IMMEDIATE CIVIL PENALTY OF $500 and an office visit will be scheduled. ANY SUBSEQUENT VIOLATIONS OF ABSCENCE OF SUPERVISION WITHIN A 12 MONTH PERIOD MAY RESULT IN A $1000 CIVIL PENALTY.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2021 and conducted by Evaluator Briana Plumboy

COMPLAINT CONTROL NUMBER: 52-CC-20210719135423

FACILITY NAME:	KEEUM		FACILITY NUMBER:	434415417
ADMINISTRATOR:	HEE SUNG KIM		FACILITY TYPE:	850
ADDRESS:	2478 WEST EL CAMINO REAL		TELEPHONE:	(650) 646-1341
CITY:	MOUNTAIN VIEW	STATE: CA	ZIP CODE:	94040
CAPACITY:	42	CENSUS: 30	DATE:	07/29/2021
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Hee Sung Kim		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Personal Rights- Staff yell at children
Other- Staff does not comply with public health directives to prevent the spread of COVID-19

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 7/29/21 at 10:18am, Licensing Program Analyst (LPA) B. Plumboy met with Director Hee Sung Kim for the purpose of an UNANNOUNCED COMPLAINT INSPECTION. Present for this inspection was 7 fingerprint clear and associated staff as well as 30 chldren in care.
It was alleged the center staff yell at children in care and the staff does not comply with public health directives to prevent the spread of COVID-19.
Based on interviews conducted and observations, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED.
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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wynn Norona	TELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Briana Plumboy	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 3