304313186-6-20-2025-06-CC-SJJG-DHTUSH-20250620155021

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304313186
Report Date: 06/20/2025
Date Signed: 06/20/2025 03:51:26 PM

Document Has Been Signed on 06/20/2025 03:51 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:	LEE, JIN		FACILITY NUMBER:	304313186
ADMINISTRATOR/ DIRECTOR:	LEE, JIN		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 822-9947
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 11	CENSUS: 11	DATE:	06/20/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Licensee, Jin Lee		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 6/20/2025, Licensing Program Analysts (LPA), Jung and Carreiro, conducted an onsite inspection for the purpose of an Annual/Random Inspection. At approximately 1:15PM, LPAs was led on a tour by licensee Jin Lee. The overall census observed was seven (7) preschool children and four (4) infant children being supervised by the licensee and one assistant. During the inspection, it was determined the facility is operating within its licensed capacity as specified on the license. Facility hours are 7:00AM-7:00PM, 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, licensee led LPAs on a tour of the inside areas identified in the facility sketch as accessible to day care children. Licensee was reminded to keep off limit areas inaccessible. The daycare areas consisted of a living room, bedroom 2, bathroom adjacent to bedroom 2, and front yard (fenced). 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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

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: LEE, JIN	FACILITY NUMBER: 304313186
	VISIT DATE: 06/20/2025

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 not stored inaccessible to children. There were cleaning compounds and medicine accessible on the kitchen counter as well as cleaning compounds accessible in the day care bathroom; see LIC 809D for deficiency. 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. LPAs verified there is a working telephone service (cellular service), licensee was reminded that childcare phone must remain in the childcare at all times.

The outdoor activity space is located in the front yard and 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 do not use the backyard for outdoor play. There is an in-ground swimming pool in the backyard. Licensee stated that they received the updated pool safety regulations from LPA Trinh, but licensee has not updated their pool safety measures.

The following requirements are for a family child care home with an in-ground swimming pool on the premises of a single dwelling. The new law states the pool must have an enclosure including, but not limited to, a fence, wall, or other barrier that isolates the pool from the home in addition to a pool cover, or alarm meeting specific American Society Testing and Materials standards. This is also known as ASTM standards. Licensee did not install a pool cover or alarm according to the updated Health and Safety code; see LIC 809D for deficiency.

Safety equipment that must be visible from the pool and available for immediate use including a life ring and rescue pole with a body hook. Licensee did not have a life ring and rescue pole with body hook available; 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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

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: LEE, JIN	FACILITY NUMBER: 304313186
	VISIT DATE: 06/20/2025

NARRATIVE

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(Page 3)
The licensee must perform a daily inspection of all above safety features before children arrive for the day. A log of the daily inspections must be maintained by the licensee and provided to the Department upon request. Licensee did not maintain a daily inspection log for pool safety; see LIC 809D for deficiency.

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 and assistant were reviewed and within compliance.

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. Licensee/assistant did not possess current EMSA approved Pediatric CPR/First Aid certification; see LIC 809D for deficiency.

Children's records were not available during the time of inspection; see LIC 809D for deficiency. Licensee stated that all the children’s records were in storage and unavailable for review. Facility had a temporary closure from late 02/2025 to 6/13/2025 due to water damage in the home. Facility re-opened on 6/16/2025. LPA observed two (2) infants from 0-12 months. Licensee did not have LIC 9227 Individual Infant Sleeping Plan and Sleep Log for infants from 0-24 months for review since children’s files were not available during the time of inspection; see LIC 809D for deficiency.

If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. The door to bedroom 2 where four (4) infants and one (1) preschool child was closed; see LIC 809D for deficiency. Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged. All five play yards in bedroom 2 where four (4) infants and one (1) preschool child was sleeping had loose sheets that did not fit tightly on the mattresses; see LIC 809D for deficiency. Cribs or play yards shall be free from all loose articles and objects. Play yards in bedroom 2 had loose articles inside including a blanket and baby bottles; see LIC 809D for deficiency.

(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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 4 of 13

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: LEE, JIN	FACILITY NUMBER: 304313186
	VISIT DATE: 06/20/2025

NARRATIVE

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(Page 4)

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

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.

LPAs 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. LPAs also informed licenseeof 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.
(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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 5 of 13

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: LEE, JIN	FACILITY NUMBER: 304313186
	VISIT DATE: 06/20/2025

NARRATIVE

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(Page 5)

Based on LPAs’ 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: 3 Type A, 7 Type B.

LPAs Jung and Carreiro informed licensee, Jin Lee, that this report dated 6/20/2025 documents 3 Type A citations. Type A citations which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

Also, LPAs Jung and Carreiro informed the licensee, Jin Lee, to provide a copy of this licensing report dated 6/20/2025 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

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.

During the exit interview, licensee Jin Lee, 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, Jin Lee.

End of Report.

NAME OF LICENSING PROGRAM MANAGER: Nguyen K Tran
NAME OF LICENSING PROGRAM ANALYST: Soo Jin Jung
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 6 of 13

Document Has Been Signed on 06/20/2025 03:51 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 06/20/2025 at 03:07 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: LEE, JIN	FACILITY NUMBER: 304313186
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102421(a)

The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). 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, 11 out of 11 children present did not have child records available for review during the time of inspection, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/23/2025
	Plan of Correction
1 2 3 4	Licensee stated that they will submit copies of files for all children enrolled to LPA via email 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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 7 of 13

Document Has Been Signed on 06/20/2025 03:51 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 06/20/2025 at 03:12 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: LEE, JIN	FACILITY NUMBER: 304313186
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102425(a)(3)

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. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that, the sheets in the play yard were not fitted tightly, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Licensee stated that they will ensure that sheets in the play yard are tightly fitted. Licensee stated they will send pictures of the fitted sheets to LPA via email by due date.

Type A

Section Cited

CCR

102425(b)

Infant Safe Sleep

(b) Cribs or play yards shall be free from all loose articles and objects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that, there were loose articles including blanket and baby bottles in the play yards during nap time, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Licensee stated they will ensure that there are no loose articles in the play yard during nap time. Licensee stated they will submit a written plan of how they will ensure that safe sleep regulations are followed to LPA 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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 8 of 13

Document Has Been Signed on 06/20/2025 03:51 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 06/20/2025 at 03:12 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: LEE, JIN	FACILITY NUMBER: 304313186
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

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
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in that, licensee did not document sleep checks every 15 minutes, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Licensee stated they will submit copies of sleep logs for all infants 0-24 months to LPA via email 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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 9 of 13

Document Has Been Signed on 06/20/2025 03:51 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 06/20/2025 at 03:12 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: LEE, JIN	FACILITY NUMBER: 304313186
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(4)

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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. 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, there were cleaning compounds accessible in the day care bathroom and cleaning compounds and medicines accessible in the kitchen, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/27/2025
	Plan of Correction
1 2 3 4	Licensee stated they will submit photos to LPA via email by due date showing that all cleaning compounds and medicines are inaccessible to children in care.

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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 10 of 13

Document Has Been Signed on 06/20/2025 03:51 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 06/20/2025 at 03:12 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: LEE, JIN	FACILITY NUMBER: 304313186
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(5)(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: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. (A)Fences shall be at least five feet high and shall be constructed so that the fence does not obscure the pool from view. The bottom and sides of the fence shall comply with Division 1, Appendix Chapter 4 of the 1994 Uniform Building Code. In addition to meeting all of the aforementioned requirements for fences, gates shall swing away from the pool, self-close and have a self-latching device located no more than six inches from the top of the gate. Pool covers shall be strong enough to completely support the weight of an adult and shall be placed on the pool and locked while the pool is not in 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 have a pool cover or alarm, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2025
	Plan of Correction
1 2 3 4	Licensee stated that they will submit proof of pool cover or alarm to LPA 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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 11 of 13

Document Has Been Signed on 06/20/2025 03:51 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 06/20/2025 at 03:12 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: LEE, JIN	FACILITY NUMBER: 304313186
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2025

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 have a life ring and rescue pole with body hook, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will show proof of life ring and rescue pole with body hook to LPA via email by due date.

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 safety inspection log of pool safety features and safety equipment, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will submit a copy of safety inspection log to LPA 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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 12 of 13

Document Has Been Signed on 06/20/2025 03:51 PM - It Cannot Be Edited

Created By: Soo Jin Jung On 06/20/2025 at 03:12 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: LEE, JIN	FACILITY NUMBER: 304313186
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102425(j)(5)

Infant Safe Sleep

The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times. 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, bedroom 2 door where five children were napping was closed, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2025
	Plan of Correction
1 2 3 4	Licensee opened the bedroom door immediately upon LPAs' request. Licensee stated that they will keep the bedroom door open at all times when children are napping in the bedroom. Licensee stated they will submit a written plan detailing that they will ensure this regulation to LPA via email by due date.

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 interview and record review, the licensee did not comply with the section cited above in that, licensee and assistant did not have at least one valid pediatric CPR and First Aid certification, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2025
	Plan of Correction
1 2 3 4	Licensee stated they will submit proof of valid pediatric first aid and CPR certification to LPA 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: 06/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2025

LIC809 (FAS) - (06/04)

Page: 13 of 13