444414178-4-20-2022-07-CC-CNEN-CDNUWY-20220420155731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444414178
Report Date: 04/20/2022
Date Signed: 04/20/2022 03:57:37 PM

Document Has Been Signed on 04/20/2022 03:57 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, NICOLE		FACILITY NUMBER:	444414178
ADMINISTRATOR:	KIM, NICOLE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(831) 332-9872
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	14	CENSUS: 11	DATE:	04/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Nicole Kim		TIME COMPLETED:	04:15 PM

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), Cortney Nelson, met with Licensee, Nicole Kim, for an unannounced Required- 1 Year Inspection. LPA was granted access to the home by the Licensee and toured both indoors and outdoors during the inspection. Upon arrival, there were 11 children (8 preschool age /3 infants), Licensee, and Assistant, Kimber Hougardy, present which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home. Hours of operation for the facility are Monday – Friday, 8:00AM-5:30PM. Licensee states that adults, over the age of 18, residing in the home are: herself and her spouse (Kirk Kim). Licensee additionally states her adult children (Rebecca, Joseph, and Jacob) are currently in college and are generally only home during the summer months. All adults residing in the home have Criminal Background Check Clearance and signed Criminal Record Statements (LIC508). Licensee was reminded that all adults 18 and over living or working in the home, 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 reviewed facility roster (LIC9040) and fire/disaster drill log during todays inspection. The last fire/disaster drill was conducted on 11/15/2021, which is compliant with the six-month requirement for homes. LPA observed a fully charged 3A40BC fire extinguisher, functioning smoke detector and carbon monoxide detector. Licensee states that she does have children in care who require Incidental Medical Services and medication (EpiPens) is properly stored out of reach of children with the proper documentation. LPA discussed creating IMS plan for children with EpiPens in care. The Licensee states that there are no weapons or firearms in the home.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

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, NICOLE	FACILITY NUMBER: 444414178
	VISIT DATE: 04/20/2022

NARRATIVE

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This facility provides Incidental Medical Services- IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. The following information regarding ADA was provided: US Department of Justice 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

Indoor areas of the home were inspected by the LPA today and observed to be clean, orderly, and safe for the day care children. Off-limits areas inside the home include: kitchen, family room, attached garage, laundry room, and entire upstairs. There are no open-faced heaters in the home. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. Furniture, such as tables, chairs, and shelves, are in good condition and safe for children. Drinking water is readily available for children in the facility via water dispenser and cups. The bathroom in the home is clean, sanitary, and operable. The Licensee has a working telephone (Licensee's cellphone) in the facility. Stairs are barricaded appropriately to keep day care children safe.

The backyard area of the home was inspected. LPA observed sufficient play-equipment and supplies for the children that are in good condition and age-appropriate. Off-limit areas outside of home include: left side-yard beyond gated play area. No outdoor bodies of water were observed during todays inspection.

LPA discussed the safe sleep regulations with Licensee 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.

11 children’s files were reviewed during todays inspection and all required documents were present, including Individual Infant Sleep Plan (LIC9227) and sleep check documentation for all infants.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

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, NICOLE	FACILITY NUMBER: 444414178
	VISIT DATE: 04/20/2022

NARRATIVE

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2 staff files (Licensee and Assistant) were reviewed and all required documents were present. The Licensee has current Mandated Reporter Training that expires on 4/3/2024 and current CPR/First-Aid that expires on 3/2023. LPA reminded Licensee that training must be renewed by all staff every 2 years. LPA advised Licensee on using Guardian for checking fingerprint clearances of new staff hired at the facility and confirming facility number on reports from DOJ/FBI.

Supervision of children was discussed with the Licensee and she understands that she must be home during day care hours and ensure that children are supervised at all times. The Licensee states that she does not transport any day care children. LPA reminded Licensee that children should not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Exit interview conducted and report was reviewed with the Licensee, Nicole Kim.

As a result of todays inspection, no deficiencies were cited.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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/process.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2022

LIC809 (FAS) - (06/04)

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