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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304206891
Report Date: 03/20/2024
Date Signed: 03/20/2024 12:53:57 PM

Document Has Been Signed on 03/20/2024 12:53 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KEUM, MARYFACILITY NUMBER:
304206891
ADMINISTRATOR:KEUM, MARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 525-7870
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
03/20/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Licensee Mary KeumTIME COMPLETED:
01:10 PM
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On 3/20/24 Licensing Program Analyst (LPA) Anna Chan conducted a Plan of Correction (POC) inspection in response to a Type A violation issued on 03/12/24, 102416.5(a) Staffing Ratio and Capacity when licensee is caring for 11 children without assistant. LPA met with Licensee Mary Keum. Current census observed was 8 children and 1 assistant and the licensee.

During the inspection it was determined the facility is operating within its licensed capacity and within compliance of staffing ratios. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

The areas cited were re-inspected and found to be corrected. A full-time assistant was hired to help licensee be in ratio to care for children. Deficiencies cleared.

No further action needed at this time. POC letters given, and correction has been received at this time.

Exit interview conducted and report was reviewed with the Licensee Mary Keum. 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.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
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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