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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415417
Report Date: 09/15/2021
Date Signed: 09/15/2021 03:20:32 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: 27DATE:
09/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Hee Sung KimTIME COMPLETED:
03:35 PM
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On September 15, 2021 at approximately 9:10am Licensing Program Analyst (LPA) Russ Haderer arrived to conduct an unannounced random annual site inspection for this school-age facility. LPA Brianna Plumboy arrived and together they viewed the check-in process and met with Site Director/owner Hee Sung Kim and toured all areas licensed for use by children in care for a health and safety inspection. There was the director, the assistant director, 7 teachers and 27 children present. All adults present are background cleared and associated to this facility.

The facility is operated in a single-story building with a playground yard in the back of the property. There are waivers for the number of children to never exceed 21 at one time and also the preschool and toddler program children will never commingle. There are 4 classrooms, a small library an office and children’s restroom with 5 working toilets and 2 working sinks and an adult bathroom. There is a waiver for the children’s bathroom that requires children to be escorted to the bathroom and be supervised at all times. Preschool children and toddlers will not commingle. There are enough towels and soap supplies. All toilets, hand washing and cleaning areas are in safe and sanitary operating condition. There is a small kitchen in classroom number 1 with a sink and refrigerator.

All play equipment is in safe condition and free from sharp, loose or pointed parts and the areas around or under high climbing equipment has appropriate cushioned material that absorbs a fall. Shade was available in the play areas and teachers are always present.

The facility has two fully charged 2A10BC fire extinguishers, the last annual inspection done in February 1, 2021. There is a working carbon monoxide detector in each classroom (tested and working). Heating and ventilation is acceptable.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KEEUM
FACILITY NUMBER: 434415417
VISIT DATE: 09/15/2021
NARRATIVE
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Due to the pandemic, the school only provides hot rice for children, they bring their own lunches from home. Children also bring their own water bottles from home. There is a menu showing snack times. The facility is clean and well organized with ample age appropriate furnishings and equipment. Surfaces including floors and counter tops are clean and toxic free. There were no hazardous items/toxins observed to be accessible to children in care today. There are no bodies of water accessible to children in care.

Disaster drills are conducted every other month, the last drill was done in July 2021.

The sign in/out sheets were reviewed. Classrooms and bathrooms have touchless trash cans with tight fitting cover for the disposal of solid waste. The facility has children that require incidental medication (EpiPen’s, inhalers).

At approximately 10:30am LPAs reviewed children's record reviewed: LPA requested and reviewed facility roster. All files selected were complete and up to date. All found to be in compliance with Title 22 regulations.

At approximately 1:00 pm LPA performed staff file review. All staff subjected to criminal review have been cleared and associated to the facility. All files were complete, up to date and found to be in compliance with Title 22 regulations.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. When any IMS is provided, an updated Plan of Operation that includes 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

Site Director was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Center. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
LIC809 (FAS) - (06/04)
Page: 2 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KEEUM
FACILITY NUMBER: 434415417
VISIT DATE: 09/15/2021
NARRATIVE
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LPA discussed the safe sleep regulations with licensee [or facility representative] and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee [facility representative] of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment. Licensee only has one child 23 months old (classified as an infant).

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Deficiencies were cited today, please refer to 809-D for details.



A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the Site Director Hee Sung Kim.
SUPERVISOR'S NAME: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KEEUM
FACILITY NUMBER: 434415417
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101226(e)(1)(B)
Health-Related Services
(e) In centers where the licensee chooses to handle medications: (1) All prescription and nonprescription medications shall be centrally stored in accordance with the requirements specified below: (B) Each container shall have an unaltered label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as there were 2 medications (an inhaler and an EpiPen) that were not kept in their original packaging (and were also expired) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2021
Plan of Correction
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Licensee will require parents of children in care to get new subscriptions and provide them to the childcare center for use in case child requires medication.
Type B
Section Cited
CCR
101238(g)
Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to children shall be stored where inaccessible to children.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as there were scissors and a knife in kept in a drawer in the kitchen accessible by children which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2021
Plan of Correction
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Licensee moved the scissors and knife to upper cabinets, immediately clearing the deficiency
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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KEEUM
FACILITY NUMBER: 434415417
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
101227(a)(1)
Food Service
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the children. Each meal shall include, at a minimum, the amount of food components as specified by Title 7, Code of Federal Regulations, Part 226.20, (Revised January 1, 1990) Requirements for Meals, for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as there were two gallons of 2% milk for children's consumption kept in the refrigerator which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2021
Plan of Correction
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Unless higher fat content milk is required and documented by a medical doctor, or a parent or legal guardian requires their child to get a higher fat-content of milk product (and the product is labeled with the child's name and only used by the intended child), milk currently on hand for children's consumption will be disposed of and only low-fat (1 percent) milk or non-fat milk will be served to children two years of age or older.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Chandra CharlesTELEPHONE: (510) 286-0966
LICENSING EVALUATOR NAME: Russell HadererTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5