444414178-3-22-2023-07-CC-CNEN-CQ6TG5-20230322144234

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 444414178
Report Date: 03/22/2023
Date Signed: 03/22/2023 02:42:39 PM

Document Has Been Signed on 03/22/2023 02:42 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: 14	DATE:	03/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:47 PM
MET WITH:	Nicole Kim		TIME COMPLETED:	02:55 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 fourteen (14) children (8 preschool-age/ 4 infants/ 2 school-age), the Licensee, and Assistant (Caitlyn) present, which is compliant with the home license capacity and ratio requirements. LPA observed all required postings near the entrance to the home and the hours of operation are Monday – Friday, 8:00AM-5:30PM. Licensee states that adults, over the age of 18, residing in the home are: herself, her spouse (Kirk), and her daughter (Rebecca). All adults residing in the home have Criminal Background Check Clearance and proof of negative tuberculosis (TB) test. 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 and observed drill was conducted on 11/10/2022, which is compliant with the six-month requirement for homes. LPA observed a fully charged 2A10BC fire extinguisher, functioning smoke detector and carbon monoxide detector. Licensee states has children in care who require Incidental Medical Services (EpiPen) and does not administer medication at this time. There are no weapons or firearms in the home. 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

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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: 03/22/2023

NARRATIVE

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Indoor areas of the home were inspected and observed to be clean, orderly, and safe for the day care children. During today's inspection, LPA observed infants and preschoolers transitioning to nap while school-age children engaged in art activities. Off-limits inside the home: entire second floor, kitchen, laundry room, family room, and attached garage. There are no open-faced heaters in the home. The Licensee states that she provides the children AM/PM snack and they bring their own lunches with them. The bathroom in the home is clean, sanitary, and operable. The Licensee has a working telephone and the stairs are barricaded appropriately to keep day care children safe.

The backyard area of the home was inspected and observed to be fenced in. LPA observed sufficient play-equipment and supplies for the children. Off-limits outside of home: right side yard area. No outdoor bodies of water were observed during todays inspection.

Fourteen children’s files, the Licensee's file, and Assistant's file were reviewed and all required documents were present including documented nap check for infants. The Licensee and Assistant have current CPR/First-Aid that expires 3/2025. The Licensee's Mandated Reporter Training expires 4/3/2024. LPA reminded that both trainings must be renewed every 2 years.

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 day care children, only in emergency or as needed. LPA reviewed the Licensee's CA drivers license (exp: 1/7/2025) and vehicle for transportation. LPA reminded 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.

SUPERVISOR'S NAME: Joel Segura	TELEPHONE: (408) 334-8550
LICENSING EVALUATOR NAME: Cortney Nelson	TELEPHONE: (916) 956-5037
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC809 (FAS) - (06/04)

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