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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434416315
Report Date: 06/08/2022
Date Signed: 06/08/2022 02:20:52 PM


Document Has Been Signed on 06/08/2022 02:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131



FACILITY NAME:KIM, SOOKKYOUNGFACILITY NUMBER:
434416315
ADMINISTRATOR:KIM, SOOKKYOUNGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 891-1538
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY:14CENSUS: 12DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:02 PM
MET WITH:Sookkyoung KimTIME COMPLETED:
02:40 PM
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On 06/09/2021 at 8:00am: Licensing Program Analyst (LPA) Pete Hernandez conducted an unannounced Required 1 Year inspection. LPA met with Licensee, Sookkyoung Kim and explained the purpose of today's inspection. Present in the home were 12 preschoolers, Licensee and two helpers Kyungju Seo and Youeong Seo. Licensee lives in the home with her husband. Licensee rents the home. The hours of operation are Monday through Friday 8:00AM to 6:00PM.
LPA toured the indoor and outdoor areas of the home during today's inspection:
In Use Areas: Classrooom and attached Bathroom, first bathroom in hall off of the Livingroom, Living room, Entire back yard except for the east side of the house that is used for parents to drop off the children. Off Limit Areas: Front yard, East side back yard gated, Kitchen, Attached Garage, Office, gated hall way and rooms 1, 2 and 3 with one hall bathroom in gated off area of the hall. Fire drills are conducted are every 6 months and last entry was done 3/24/22. Licensee will maintain a current children's' roster. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is orderly, and safe for the day care children.
LPA observed a fully charged 2A10BC fire extinguisher. There are working smoke & carbon monoxide detectors in the home with fire pull stations. LPA did not observe any bodies of water on the property. Licensee understands that all pools, spas, hot tubs, fish ponds, or similar bodies of water shall be covered or fenced as specified in title 22 regulations to be inaccessible to children. Licensee states that there are no weapons or firearms in the home. All detergents, cleaning compounds, other similar items and poisons are in the garage or out of reach, and are inaccessible to children.
REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATE 6/8/2022.:
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIM, SOOKKYOUNG
FACILITY NUMBER: 434416315
VISIT DATE: 06/08/2022
NARRATIVE
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 6/8/2022):

LPA informed the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Licensee does not have an IMS. 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

The Licensee states that she does not transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.


Supervision of children was discussed with the Licensee. Licensee understands that she must be present in the home at least 80 percent of the hours the day care is in operation and ensure that the children are supervised at all times. The Licensee understands her capacity options. The Licensee states that she does not transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIM, SOOKKYOUNG
FACILITY NUMBER: 434416315
VISIT DATE: 06/08/2022
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LPA went over Regulation 102425(j) and (j)(2)(D) regarding infant care and LIC 9227 (Infant Sleeping Plan). LPA Provided a copy. The provider shall supervise infants while they are sleeping.

LPA reviewed the files of 12 children and 3 Staff. Licensee is very organized and all required documentation was current and in the file.

Licensee's CPR and First Aid Card expired. She has already signed up for a class to get it updated.

Licensee provided a copy of her last children's roster to the LPA.

LPA observed all required postings on the wall next to the front door.

Type A language: Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. A copy of this report and appeals rights were discussed and left with the Licensee, Sookkyoung Kim, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISOR'S NAME: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 06/08/2022 02:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: KIM, SOOKKYOUNG
FACILITY NUMBER: 434416315

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's review of files, Licensee does not have current Pediatric CPR/First Aid certification on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/29/2022
Plan of Correction
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BY POC DUE DATE Licensee agrees to provide proof of CPR/First Aid completion to Licensing office
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: Joel SeguraTELEPHONE: (408) 324-2155
LICENSING EVALUATOR NAME: Pietro HernandezTELEPHONE: (408) 598-9250
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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