434417021-4-22-2022-07-CC-MSMS-CDQNY2-20220422105201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434417021
Report Date: 04/22/2022
Date Signed: 04/22/2022 10:52:11 AM

Document Has Been Signed on 04/22/2022 10:52 AM - 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, JIAE		FACILITY NUMBER:	434417021
ADMINISTRATOR:	JIAE KIM		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(213) 503-8542
CITY:	SUNNYVALE	STATE: CA	ZIP CODE:	94087
CAPACITY:	14	CENSUS: 0	DATE:	04/22/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Jiae Kim		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Mel Matos met with Applicant, Jiae Kim, for an announced prelicensing inspection at 798 Londonberry Drive, Sunnyvale, CA 94087. LPA was greeted by Jiae Kim, Applicant, and granted access to the home. The adults that reside in the home and who were also present during today's inspection are the Applicant, Applicant's mother, Mi Hong, and Applicant's brother, Hyo Kim. There are no minor children residing in the home. Days and hours of operation will be Monday - Friday from 8:00 AM to 5:30 PM. Applicant has completed her Preventative Health and Safety Child Care Training on June 13, 2021 and a copy of the certification is on file. Applicant's CPR and First Aid certifications are current and expire on 05/2023. Applicant completed the Mandated Reporter Training on 04/29/22. A copy of current TB test, flu, Mmr, and Tdap immunizations are on file. Applicant rents the home and a copy of the Owner/Landlord Notification (LIC 9151) and Owner/Landlord Consent (LIC 9149) forms are on file. Applicant does not have liability insurance at this time and will issue the Affidavit Regarding Liability Insurance for Family Child Care Home (FCCH) until she does obtain coverage. LPA toured the indoor and outdoor areas during today's inspection. There are no stairs or fireplace units in the home. Off limit areas indoors are: Bedroom 1 & 2, one bathroom, living room, kitchen, and attached garage. Off limit areas outdoors: right side area of the home. There is a play structure in the backyard area that is safe/secure for children; however, the structure needs to be secured to the ground and additional resilient materials need to be added. The home is clean and orderly, with central heating/air conditioning, and ventilation for safety & comfort. There is sufficient toys, supplies, and equipment for the day care children both indoors/outdoors. LPAs observed a fully charged fire extinguisher (3A40BC), working combo smoke and carbon monoxide detectors, fenced backyard, and no bodies of water. Applicant states that she does not have any pets or weapons in the home.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KIM, JIAE	FACILITY NUMBER: 434417021
	VISIT DATE: 04/22/2022

NARRATIVE

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Forms of discipline to be used by Applicant: talking to children/redirection. Applicant states that a child will be isolated in the family room area if necessary due to illness or communicable disease.
Cleaning Products, toxic agents, medications, and sharp objects were inaccessible to children. LPA reminded Applicant that smoking, baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes.

Applicant understands that children's personal rights should not be violated; including no corporal punishment. isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries, heat related illnesses, and requirements for assistant/substitute were also discussed. LPA informed Applicant that fire/disaster drills must be practiced at least once every 6 months and documented.

Jiae Kim, Applicant, was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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 licensed Family Child Care Home. 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.

LPA discussed the requirements of AB 633 with the Applicant. Applicant understands the AB 633 fact sheet/copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224). LPA discussed "zero tolerance" related regulations with the Applicant and advised her of the assessment of an immediate $500 civil penalty for any violation of a "zero tolerance" related regulation. An ongoing civil penalty of $100 per day continues until the violation(s) is corrected.

LPA provided and reviewed the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted.

LPA provided and discussed the safe sleep regulations with Applicant 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 Jiae 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

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KIM, JIAE	FACILITY NUMBER: 434417021
	VISIT DATE: 04/22/2022

NARRATIVE

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APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS:
Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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

PIN 22-02-CCP - Best Practices Related to the Provision of Incidental Medical Services in Child Care Center and Family Care Homes was provided to Applicant.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

Exit interview conducted and report was reviewed with the Applicant, Jiae Kim, Applicant, and advised her that the following items need to be completed and corrected prior to approval of a large Family Child Care Home License:

1) Play structure needs to be secured to the ground and additional resilient materials need to be added.
2) Follow up inspection by LPA Matos has been completed to verify correction of item #1.

SUPERVISOR'S NAME: Diana Stephenson	TELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S Matos	TELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022

LIC809 (FAS) - (06/04)

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