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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 192008424
Report Date: 11/04/2024
Date Signed: 11/04/2024 12:36:53 PM

Document Has Been Signed on 11/04/2024 12:36 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:JAE FAMILY CHILD CAREFACILITY NUMBER:
192008424
ADMINISTRATOR/
DIRECTOR:		JAE, SOON GOOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 345-7884
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 6DATE:
11/04/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Licensee Soon Goo JaeTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 11/04/2024 at 8:20am Licensing Program Analyst (LPA), Jeanine Lipsey conducted an unannounced Required 3-year Annual Inspection and was met by Licensee Soon Jae and spouse Sang Jae. Entrance checklist was provided. LPA observed 4 children in care today 1 was an infant. Capacity as specified on the license is being maintained. Days and hours of operation are Monday through Friday 7am to 7pm. Home does not have the required amount of liability insurance, a Signed Affidavit Regarding Liability Insurance was not present in the children files.

LPA observed the following required postings: License, PUB 394 Notification of Parents’ Rights Poster, and LIC 9148 Earthquake Preparedness Checklist. LPA advised all LIC9213 Notice of Site Visits shall be posted for 30 days after each site visit. LPA advised, any licensing report documenting a Type A citation must be posted for 30 days. LPA advised LIC610A Emergency Disaster Plan and a disaster/fire drill log shall be available to view with disaster drills completed at lease every six months. LPA observed log of drills being conducted monthly.


LPA toured the home inside and outside. This is a 1 story, 3-bedroom, 3-bathroom home with living/ding room, detached playroom and detached garage, kitchen, a large, attached room, used for childcare that have 2 bathrooms office and small eating area. The areas that are accessible to children: are the large, attached room, used for childcare that have 2 bathrooms office and small eating area and the backyard for outdoor activities. Isolation area will be located in the small eating area. The main home is off limits to children which include: 3 Bedrooms 1 bathroom, kitchen, living/dining room.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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Document Has Been Signed on 11/04/2024 12:36 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 11/04/2024 at 10:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JAE FAMILY CHILD CARE
FACILITY NUMBER: 192008424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that licensee and spouse do not have prrof of TB, measels and t-dap which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee will send proof of immunizations by correction date via email.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that the infant child is missing lic 9227 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee will send copy of completed lic 9227 by correction date via email.
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:Betty Bell
LICENSING EVALUATOR NAME:Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 11/04/2024 12:36 PM - It Cannot Be Edited


Created By: Jeanine Lipsey On 11/04/2024 at 10:30 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JAE FAMILY CHILD CARE
FACILITY NUMBER: 192008424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)(c)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following: Time of each 15-minute check

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in that the 15 minute checks are not being documented which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee will send proof of 15 minute checks by correction date via email.
Type B
Section Cited
CCR
102417(m)(3)
Operation of a Family Child Care Home

(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that 5 of 5 children files reviewed did not have lic 282 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Licensee will send copy of completed LIC 282 by correction date via email.
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:Betty Bell
LICENSING EVALUATOR NAME:Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JAE FAMILY CHILD CARE
FACILITY NUMBER: 192008424
VISIT DATE: 11/04/2024
NARRATIVE
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LPA did not observe any poisons resent during the inspection. Detergents, cleaning compounds, medication and other hazardous item were made inaccessible to children. Per applicant, there are no firearms, weapons or bodies of water on the premises. LPA observed the clothes dryer outside in the play area that need a safety lock to prevent children access. LPA did not observe stairs of fireplace or open face heater.

LPA observed first aid kit was missing tweezers. LPA Lipsey observed a working carbon monoxide detector in the playroom, LPA was able to hear a successful test. The smoke detector was also located in the playroom. Fire extinguisher 2A10BC was observed, located in the office and was serviced on 1/16/2024. Electrical outlets were observed to be inaccessible to children in care with the use of plug covers. The home was observed to be clean and orderly with heating and ventilation. LPA observed safe toys, play equipment, and materials. LPA verified the home has a working telephone service. LPA observed the outdoor area to be fenced and free from hazards LPA observed multiple play equipment in good repair. Licensee ensures that children in care are always supervised.

Licensee’s pediatric CPR/First Aid was completed on 5/30/2023 and Mandated Reporter Training was not Completed. Licensee and spouse are missing proof of TB test, measles and t-dap. Licensee will get proof of immunizations and training by correction date.

For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-carecenters/.

On this date, 11/03/2024, the California Attorney General - Megan's Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JAE FAMILY CHILD CARE
FACILITY NUMBER: 192008424
VISIT DATE: 11/04/2024
NARRATIVE
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

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-and­resources/safe-slee as an additional resource. LPA also informed licensee 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.

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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

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SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JAE FAMILY CHILD CARE
FACILITY NUMBER: 192008424
VISIT DATE: 11/04/2024
NARRATIVE
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During the exit interview, the Licensee Soon Jae and spouse Sang Jae confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Based on LPA's observations, the following deficiencies listed on the attached LIC809D (deficiency page) are being cited in accordance with Title 22, Division 12, Chapter 3, of the California Code of Regulations. Deficiencies that are being cited need to be cleared to protect the children's health & safety.

The following corrections need to be completed by the correction date of 11/25/24 and sent to LPA via email.

1. The clothes Dryer outside in the play area needs safety lock to prevent children access.
2. Send proof of immunization's, TB, Measles, & T-dap for licensee and spouse.
3. Copy of LIC 282 in each children's file.
4. Copy of LIC 9227 for the infant child.


5. Record of Proof of 15 minute checks being conducted for the infant child.

Exit interview conducted and report was reviewed with the licensee Soon Jae and spouse Sang Jae

A notice of site visit was given and advised Licensee that it must remain posted for 30 days.

SUPERVISORS NAME: Betty Bell
LICENSING EVALUATOR NAME: Jeanine Lipsey
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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