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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304206891
Report Date: 01/29/2025
Date Signed: 01/29/2025 02:39:54 PM

Document Has Been Signed on 01/29/2025 02:39 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/
DIRECTOR:		KEUM, MARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 525-7870
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
01/29/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Licensee, Mary KeumTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 1/29/2025 at 12:35pm, an Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Sarah Garcia. LPA met with licensee, Mary Keum and census was taken. LPA observed 11 children with 2 assistants in day care area. Licensee was operating within the licensed capacity as specified on license. 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. Currently there are 2 adults including the licensee living in the facility. Facility Day care hours are 8am-6pm, Monday through Friday.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of closed and locked doors. Per licensee, the primary child care area consists of the living room and den which is accessed through the front door. The children walk through the hallway to the bathroom. There are working carbon monoxide, smoke detector, and fire extinguisher 3A40BC in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. LPA verified there is a working telephone service. LPA inspected the outdoor area and observed the space to be safe and free from any immediate and/or potential risks to the children in care. No poisons or other items were observed which could pose a danger to children or if they were observed, they were locked or inaccessible. There are no bodies of water on the premises.

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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEUM, MARY
FACILITY NUMBER: 304206891
VISIT DATE: 01/29/2025
NARRATIVE
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The licensee does have a current roster of children in care. (6) children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. LPA did not observe any infants from 0-12 months.

The licensee Pediatric CPR/First Aid certification expires 01/2027. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. Proof of immunization against pertussis, measles for licensee and assistants were reviewed. 2 out of 3 staff did not have immunizations from measles and pertussis. Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. The licensee and assistants are exempt from this requirement due to the training not being available in Korean.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

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: Martha Malane
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEUM, MARY
FACILITY NUMBER: 304206891
VISIT DATE: 01/29/2025
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The licensee understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian



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.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms.
The licensee was informed of the Important Updates available at www.ccld.ca.gov and may request to be added to an email list to receive Community Care Licensing Important Notifications from the above website and selecting Receive Important Updates link.

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-and-resources/safe-sleep 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.


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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEUM, MARY
FACILITY NUMBER: 304206891
VISIT DATE: 01/29/2025
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The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed and cited at the time of the visit. The following violations were observed and cited today: Health and Safety Section 1597.622(c) (see LIC 809D).

During the exit interview, the LICENSEE Mary Keum, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Mary Keum.

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.

End of Report.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/29/2025 02:39 PM - It Cannot Be Edited


Created By: Sarah Garcia On 01/29/2025 at 02:00 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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KEUM, MARY
FACILITY NUMBER: 304206891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025

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 2 out of 3 staff files did not have immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/12/2025
Plan of Correction
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Licensee will obtain (2) immunizations and retain in facility files. Licensee will submit immunzation records to LPA via email sarah.garcia@dss.ca.gov by 5pm on 2/12/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Martha Malane
LICENSING EVALUATOR NAME:Sarah Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


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