304300227-5-21-2025-06-CC-SJJG-DGVVP3-20250521163604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304300227
Report Date: 05/21/2025
Date Signed: 05/21/2025 04:38:03 PM

Document Has Been Signed on 05/21/2025 04:38 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:	SUH, OLIVIA		FACILITY NUMBER:	304300227
ADMINISTRATOR/ DIRECTOR:	SUH, OLIVIA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 562-8800
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 3	CENSUS: 3	DATE:	05/21/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:10 PM
MET WITH:	Licensee, Olivia Suh		TIME VISIT/ INSPECTION COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/21/2025, Licensing Program Analyst (LPA), Christine Jung, conducted an onsite inspection for the purpose of an Annual Inspection. At 1:10PM, LPA was led on a tour by licensee, Olivia Suh. The overall census observed was two (2) preschool children and one (1) infant child with one (1) assistant and licensee. During the inspection, it was determined the facility is operating within its licensed capacity as specified on the license. Facility hours are 8:00AM – 6:00PM, Monday through Friday. The Facility Personnel Report Summary reviewed on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. 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. During today’s inspection, LPA and licensee toured the inside areas identified in the facility sketch as accessible to day care children. Off limits areas are made inaccessible by means of closed doors. LPA reminded licensee to keep off-limit areas inaccessible. The daycare areas consisted of a living room located at the end of the hallway, downstairs bathroom located in the hallway, and a section of the backyard. There is direct access to the backyard from the living room where care is provided. There were working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory requirements. (Go to Page 2)

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Soo Jin Jung
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: SUH, OLIVIA	FACILITY NUMBER: 304300227
	VISIT DATE: 05/21/2025

NARRATIVE

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(Page 2)
Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. There were no poisons or other items observed which could pose a danger to children. If they were observed, they were locked or inaccessible. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspection. The home had age-appropriate toys for the ages served. LPA verified there is a working telephone service (landline and cellular service), licensee was reminded that childcare phone must remain in the childcare at all times. Licensee confirmed that the last emergency drill was conducted in 12/2021. Facility is required to conduct an emergency drill at least once every six months and maintain a log for the drills; see LIC 809D for deficiency.

The outdoor activity space was inspected for compliance. The space was enclosed by a fence at least five feet in height. The surface of the outdoor activity space was maintained and free of hazards. Licensee stated that they use a section of the backyard for outdoor play. The outdoor play area is separated by a gate. On the other side of the gate is an in-ground swimming pool. Licensee stated that they have not reviewed the updated pool safety regulations, although they have received phone calls and emails from the Regional Office (RO) regarding the updated regulations. Licensee did not have an approved safety pool cover or alarm in addition to an enclosure; see LIC 809D for deficiency. Licensee did not have the following safety equipment visible from the swimming pool and readily available for immediate use; see LIC 809D for deficiency. Licensee did not perform a daily inspection of the drowning prevention safety features and safety equipment; see LIC 809D for deficiency. LPA provided licensee a printed copy of the Pool Regulations and reviewed the regulations with licensee.

Licensee and assistant’s files were reviewed during the facility inspection on this date. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against influenza, pertussis, and measles for licensee/assistant were reviewed and not within compliance. The licensee and assistant did not have proof of immunization against influenza (or written declaration to decline); see LIC 809D for deficiency.

(Go to Page 3)

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Soo Jin Jung
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

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: SUH, OLIVIA	FACILITY NUMBER: 304300227
	VISIT DATE: 05/21/2025

NARRATIVE

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(Page 3)
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 employees are exempt from this requirement due to the training not being available in Korean. Licensee does not possess current EMSA approved Pediatric CPR/First Aid certifications; see LIC 809D for deficiency.

Licensee did not maintain personnel records for their assistant; see LIC 809D for deficiency.

Two children's records were reviewed. Licensee did not have records for Child 3 (C3) for review, and licensee confirmed that they did not obtain enrollment documents including immunization record for C3; see LIC 809D for deficiency. LPA issued Technical Violations (TV) for additional documents missing for C3. LPA provided licensee with the following documents to complete for C3: LIC 282, LIC 700, LIC 627, LIC 995A, LIC 9150. LPA did not observe infants from 0-12 months. Licensee did not have Sleep Log for infant from 0-24 months in children’s files; see LIC 809D for deficiency.

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/.

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 for and supervise children while absent. The substitute adult must have the required criminal record clearance, child abuse index clearance, 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

(Go to Page 4)

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Soo Jin Jung
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 4 of 15

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: SUH, OLIVIA	FACILITY NUMBER: 304300227
	VISIT DATE: 05/21/2025

NARRATIVE

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(Page 4)
CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

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. LPA provided licensee a copy of the Safe Sleep regulations, sample Sleep Log, and LIC 9227 Individual Infant Sleeping Plan.

Based on LPA’s observations, record reviews, and interviews, the following violations were observed and are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1. See LIC 809D for violations cited: 9 Type B.
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 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.

(Go to Page 5)

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Soo Jin Jung
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 5 of 15

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: SUH, OLIVIA	FACILITY NUMBER: 304300227
	VISIT DATE: 05/21/2025

NARRATIVE

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(Page 5)
During the exit interview, the licensee, Olivia Suh, 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, Olivia Suh.

LPA Jung provided Korean interpretation throughout the inspection and report review.

End of Report.

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Soo Jin Jung
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 6 of 15

Document Has Been Signed on 05/21/2025 04:38 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 05/21/2025 at 03:31 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: SUH, OLIVIA	FACILITY NUMBER: 304300227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2025

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that, licensee did not conduct emergency drills at least once every six months, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will conduct an emergency drill and send LPA a copy of the updated emergency drill log via email by due date.

Type B

Section Cited

HSC

1596.814(a)(1)(B)

Pool Safety

(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (1) The swimming pool shall be equipped with, at minimum, the following drowning prevention safety features: (B) In addition to the characteristics described in subparagraph (A), at least one of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that, licensee did not obtain a pool cover or pool alarm in addition to the pool gate, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will purchase a pool alarm or pool cover per regulations and send LPA proof of purchase via email by due date. Copy of updated pool regulations were provided to licensee.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nguyen K Tran
NAME OF LICENSING PROGRAM MANAGER:

	Soo Jin Jung
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 7 of 15

Document Has Been Signed on 05/21/2025 04:38 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 05/21/2025 at 03:31 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: SUH, OLIVIA	FACILITY NUMBER: 304300227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.814(a)(2)

Pool Safety

(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (2) The licensee shall have the following safety equipment visible from the swimming pool and readily available for immediate use: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in that, licensee did not obtain a life ring and rescue pole per regulation, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will obtain a life ring and rescue pole per regulation and submit proof to LPA via email by due date. Copy of updated pool regulations were provided to licensee.

Type B

Section Cited

HSC

1596.814(a)(3)

Pool Safety

(a) A licensed family daycare home operated at a private single-family dwelling with an in-ground swimming pool on the premises shall comply with all of the following requirements: (3) A licensee shall perform a daily inspection of the drowning prevention safety features and safety equipment before opening the facility and maintain a log of the inspections to be provided to the department upon request. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that, licensee did not maintain a log of the pool safety and equipment inspections, which pose a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee stated that they will maintain a log of daily inspections for pool safety and equipment and provide a copy to LPA via email by due date. Copy of updated pool regulations were provided to licensee.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nguyen K Tran
NAME OF LICENSING PROGRAM MANAGER:

	Soo Jin Jung
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 8 of 15

Document Has Been Signed on 05/21/2025 04:38 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 05/21/2025 at 03:31 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: SUH, OLIVIA	FACILITY NUMBER: 304300227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that, licensee did not maintain a copy of a current CPR & First Aid certificate for review, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will provide current proof of CPR & First Aid training certificate to LPA via email by due date.

Type B

Section Cited

CCR

102416.1(a)

Personnel Records

(a) Personnel records shall be maintained on each employee and shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on nterview and record review, the licensee did not comply with the section cited above in that, licensee did not maintain personnel records for Assistant 1 (A1), which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will create and maintain personnel records for A1. LPA provided licensee with documents needed for A1's file. Licensee stated they will provide LPA with a copy of A1's file via email by due 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.

	Nguyen K Tran
NAME OF LICENSING PROGRAM MANAGER:

	Soo Jin Jung
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 9 of 15

Document Has Been Signed on 05/21/2025 04:38 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 05/21/2025 at 03:31 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: SUH, OLIVIA	FACILITY NUMBER: 304300227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that, licensee and A1 did not have proof of influenza or statement to decline, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will submit to LPA via email copies of proof of influenza or statement to decline by due date.

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that, licensee did not obtain immunization records for Child 3 (C3), which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will obtain C3's immunization record and complete PM 286 then provide LPA copies of records via email by due 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.

	Nguyen K Tran
NAME OF LICENSING PROGRAM MANAGER:

	Soo Jin Jung
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 10 of 15

Document Has Been Signed on 05/21/2025 04:38 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 05/21/2025 at 03:31 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: SUH, OLIVIA	FACILITY NUMBER: 304300227
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(2)(D)

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: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that, licensee did not maintain Sleep Logs for C3, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2025
	Plan of Correction
1 2 3 4	Licensee stated they will maintain Sleep Logs for C3 and all future infants who may enroll. Licensee stated they will provide LPA via email copies of Sleep Logs for C3 for 5/22-23/25 by due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Nguyen K Tran
NAME OF LICENSING PROGRAM MANAGER:

	Soo Jin Jung
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025

LIC809 (FAS) - (06/04)

Page: 11 of 15