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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198012306
Report Date: 12/05/2024
Date Signed: 12/05/2024 05:01:06 PM

Document Has Been Signed on 12/05/2024 05:01 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
MONTEREY PARK CC RO, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754
FACILITY NAME:DEJONG FAMILY CHILD CAREFACILITY NUMBER:
198012306
ADMINISTRATOR/
DIRECTOR:		DEJONG, AIDAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 764-4077
CITY:POMONASTATE: CAZIP CODE:
91767
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 13DATE:
12/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Licensee Aida DejongTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analysts (LPA)s Stephanie Li and Joanne Solorio Campos conducted a Case Management-Deficiencies visit on 12/5/24 to address deficiencies revealed during a deliver findings complaint visit. A COVID risk assessment was conducted. Two assistants were present with 13 children. Licensing staff met with Licensee Aida Dejong to whom the reason for the visit was explained. Licensee provided a tour of the facility. Present during the inspection was 2 staff, 1 therapists and 13 children.

During todays findings visit, LPA's observed new children who may be under the age of 2. Upon children's file review it was discovered that 2 children under the age of 2 do not have the required licensing forms on file completed and signed by parents. LPA's were able to verify the parent information, age of children and approved provider services through PUSD contract. Children are missing ID LIC700, parents right LIC995, medical consent LIC627, immunizations, INSF LIC9227 and affidavit liability waiver LIC282.

Based on interview and record review, deficiencies are being cited on the following page LIC809D for missing documents for C1 (10mth old) and C2 (1 yr old) per California Code of Regulations, Title 22. Deficiencies cited need to be cleared to protect the health and safety of children in care.

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.

Exit interview conducted and report was reviewed with Licensee Aida Dejong
SUPERVISORS NAME: Christina Gabelman
LICENSING EVALUATOR NAME: Stephanie Li
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/05/2024 05:01 PM - It Cannot Be Edited


Created By: Stephanie Li On 12/05/2024 at 04:27 PM
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
, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: DEJONG FAMILY CHILD CARE
FACILITY NUMBER: 198012306

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2024
Section Cited
CCR
102419(d)(1)

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(1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or authorized representative has received and read the LIC 995A. The bottom portion of this form must be kept in the child’s file as proof that the parent or authorized representative has been notified of his or her rights and received a copy of the Caregiver Background Check Process, LIC 995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).
This requirement was not met evidenced by:
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Per licensee, she will have parents fill out form LIC995 and submit photo to LPA S Li by 12/10/24
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Based on record review, two children were missing parents right acknowledgement in their files, which poses a health and safety risk for children in care.
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Type B
12/10/2024
Section Cited
CCR102417(g)(7)

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(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement was not met evidenced by:
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Per licensee, she will have parents fill out forms LIC700 and LIC627 by 12/10/24 and text photo to LPA S Li.
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Based on record review, two children were missing emergency cards and medical consent in children's files, which poses a health and safety risk for children in care.
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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:Christina Gabelman
LICENSING EVALUATOR NAME:Stephanie Li
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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