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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198019997
Report Date: 10/23/2024
Date Signed: 11/08/2024 11:12:56 AM

Document Has Been Signed on 11/08/2024 11:12 AM - 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 SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:CHIM FAMILY CHILD CAREFACILITY NUMBER:
198019997
ADMINISTRATOR/
DIRECTOR:		LESLIE CHIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 896-7510
CITY:LAKEWOODSTATE: CAZIP CODE:
90712
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
10/23/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Leslie ChimTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jonnisha Culbert attempted to performed an unannounced Annual Random Inspection at the facility noted above. LPA met with licensee Lleslie Chim stated the purpose of today’s visit, and provided her with an entrance checklist for family childcare homes (LIC126). Licensee guided LPA on a tour of the facility of both indoor and outdoor. Individuals residing in the home were discussed and noted. Present at the time of inspection were licensee, assistant 1, 7 children, adult 1, and 3 construction workers. Per licensee, hours of operation are Monday through Friday 7am to 5:30 pm.

All areas accessible to children were inspected, personnel and children files were reviewed..

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.

Due to time restraints the Annual/Random visit will be completed on a future date. LPA will address deficiencies observed on today at a future visit.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Leslie Chim.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Jonnisha Culbert
LICENSING EVALUATOR SIGNATURE: DATE: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/23/2024
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 6
Document Has Been Signed on 11/08/2024 11:12 AM - It Cannot Be Edited


Created By: Jonnisha Culbert On 10/23/2024 at 03:42 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(b)
Operation of A Family Child Care Home
(b) The home shall be kept clean and orderly, with heating and ventilation for safety and comfort.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above and areas that are utilized by children are not orderly. Per licensee, due the remodel things are everywhere. This poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Per licensee, they will continue to remove items out of areas utilitzed by children. LPA observed that bikes and plants were removed from children's play area. Per licensee, they will submit proof that areas utilitzed by children are orderly by proof of correction date. Licensee will email photo proof to LPA J. Culbert.
Type B
Section Cited
CCR
102417(g)(1)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguisher have not been replaced or serviced. LPA observed service tag dated August 24, 2022. This pose a potential safety risk risk to persons in care.
POC Due Date: 11/29/2024
Plan of Correction
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Per licensee, they will get the fire extinguisher serviced and submit via email a photo of service tag to LPA J. Culbert by proof of correction date.
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:Valarie Cook
LICENSING EVALUATOR NAME:Jonnisha Culbert
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/08/2024 11:12 AM - It Cannot Be Edited


Created By: Jonnisha Culbert On 10/23/2024 at 03:42 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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This required is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above and drills have not been conducted. During record review, LPA identified that licensee was previously cited for not performing and documenting drills. Per licensee, they have not performed a drill since February and there is no documentation for the drill performd. This pose a potential safety risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Per licensee, they will perform, document, and submit proof that drill was performed by plan of correction date. Licensee will send it to LPA J. Culbert via email.
Type B
Section Cited
CCR
102425(a)(4)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (4) Mattresses shall be made specifically for the size crib or play yard in which they are placed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 crib had multiple mattresses insided of the it. LPA observed to different mattresses stacked on top of each other inside Child 1's crib. Per licensee, one of the mattresses belong to a play yard. This posed a potential safety risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Licensee immediately removed play yard mattress from the crib. LPA advised licensee to review safe sleep regulation. Licensee agreed to review safe sleep regulation and complete a signed statement expressing that they understand regulations by proof of corretion date to LPA J. Culbert.
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:Valarie Cook
LICENSING EVALUATOR NAME:Jonnisha Culbert
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/08/2024 11:12 AM - It Cannot Be Edited


Created By: Jonnisha Culbert On 10/23/2024 at 03:42 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 infants' records reviewed did not have documentation to show that infants were supervised while they were sleep. LPA did not observe forms during record review. Per licensee, they stopped logging infant sleep for a while. This pose a potential safety risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Per licensee, they will start sleep log for all infants and record 15 minute logs and submit documentation to LPA J. Culbert by proof of correction date via email.
Type B
Section Cited
CCR
102416.3(a)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above and the home is currently being remodeled. Per licensee, the remodel started about 6 weeks ago and will continue to the end of November. LPA observed the workers working in the home. This poses a potential health, safety, and personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Per licensee, they will complete an unusally incident report form and submit it by proof of correction date to LPA J. Culbert 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:Valarie Cook
LICENSING EVALUATOR NAME:Jonnisha Culbert
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/08/2024 11:12 AM - It Cannot Be Edited


Created By: Jonnisha Culbert On 10/23/2024 at 03:42 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416.3(a)(6)
Alterations to Existing Building or Grounds
(a) Prior to making alterations or additions to a family child care home or grounds, the licensee shall notify the Department of the proposed changed, including, but not limited to, the following: (6) Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above and the area of the home previously identified as off limits is curreltly being used by children in carel. LPA observed children eating in playing in the area that was previously identified as off limits. Per licensee, the area is currently on limits. This pose a potential safety risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Per licensee, they will complete a new facility sketch and appropriatelly identify the area of the home that are off limits to children in care. Licensee will submit the sketch by proof of correction date to LPA via email.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not comply with the section cited above in 1out of 1 asisstant does not have proof that they have been immunized against influenza, pertussis, and measles. LPA reviewed asisstants record and did not find immunization proof on file. Per licensee, assistant is working on obtaining proof. This pose a potential health and safety risk to persons in care.
POC Due Date: 11/04/2024
Plan of Correction
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Per licensee, assistant 1 will obtain and submit immunization records by proof of correction date and submit it to LPA J.Cullbert 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:Valarie Cook
LICENSING EVALUATOR NAME:Jonnisha Culbert
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 11/08/2024 11:12 AM - It Cannot Be Edited


Created By: Jonnisha Culbert On 10/23/2024 at 03:42 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 CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: CHIM FAMILY CHILD CARE
FACILITY NUMBER: 198019997

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 and interview, the licensee did not comply with the section cited above in 1out of 1 infant did not have a completed LIC 9227 in their file. Per licensee, they did not have parents complete one. This poses a potential safety risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Per licensee, they will have parent complete form and licensee will submit it to LPA J. Culbert by proof of correction datevia email.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Valarie Cook
LICENSING EVALUATOR NAME:Jonnisha Culbert
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024


LIC809 (FAS) - (06/04)
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