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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417021
Report Date: 05/17/2022
Date Signed: 05/17/2022 04:16:42 PM


Document Has Been Signed on 05/17/2022 04:16 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, JIAEFACILITY NUMBER:
434417021
ADMINISTRATOR:JIAE KIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 503-8542
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY:14CENSUS: 0DATE:
05/17/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Jiae KimTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Mel Matos met with Jiae Kim, Applicant, for an announced follow up prelicensing inspection. The initial prelicensing inspection was completed on April 22, 2022 and the Applicant was advised that the following item needed to be completed before a large Family Child Care Home License can be approved.

1) Play structure needs to be secured to the ground and additional resilient materials need to be added.

LPA toured the backyard area of the home with Jiae Kim during today's inspection. LPA observed that the play structure is secured to the ground via ground stakes. There are also sufficient resilient materials (rubber tiles & artificial grass) underneath and surrounding the play structure.

Note: A letter verifying Applicant's experience working in a licensed child care center since July 8, 2019. An approved fire clearance from the Sunnyvale Department of Public Safety was also received on November 29, 2021.

LPA concludes that the Applicant has completed all requirements and thus a large Family Child Care Home License is approved effective today, May 17, 2022.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2158
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:
DATE: 05/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/17/2022
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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