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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313570
Report Date: 09/22/2022
Date Signed: 09/22/2022 12:51:40 PM

Document Has Been Signed on 09/22/2022 12:51 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
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:OH, IM KYOUNGFACILITY NUMBER:
304313570
ADMINISTRATOR:OH, IM KYOUNGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(657) 239-0849
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
09/22/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Im Kyoung Oh, LicenseeTIME COMPLETED:
10:00 AM
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A unannounced inspection was conducted at the facility by Licensing Program Analyst (LPA) Tran and LPA Duron. LPAs observed licensee caring for 4 children including 2 infants. Licensee was operating within the licensed capacity and met staff-child ratio as specified on license. LPA informed Licensee the purpose of the inspection is to deliver the amended report from the original report on 09/15/2022.

Amended report was reviewed and provided to Licensee Im Kyoung Oh.

Exit interview was conducted. The Notice of Site Visit was posted. Facility representative was informed that the Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalty of $100. “The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights.” This report LIC 9099 was provided to the licensee. First level appeal is to Regional Manager, address is above on the report.
SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Nguyen K Tran
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2022
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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