<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313626
Report Date: 06/11/2026
Date Signed: 06/11/2026 12:28:08 PM

Document Has Been Signed on 06/11/2026 12:28 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:KIM, MONICAFACILITY NUMBER:
304313626
ADMINISTRATOR/
DIRECTOR:		KIM, MONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 745-5866
CITY:LA PALMASTATE: CAZIP CODE:
90623
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 14DATE:
06/11/2026
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee Monica KimTIME VISIT/
INSPECTION COMPLETED:
12:45 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
(Page 1)

An annual inspection was conducted at the facility by Licensing Program Analyst (LPA) Giselle Lucero. Upon entry, LPA observed the licensee and two assistants supervising 12 children, consisting of 3 infants and 9 preschool aged children, who were playing in the living room.

At approximately 9:40 AM, while seated at the dining room table, LPA heard an infant crying from another room. LPA asked the licensee whether an additional child was present in a separate room. The licensee confirmed that an infant was sleeping. LPA accompanied the licensee to a bedroom and observed a third assistant in the room with two infants.

This resulted in a total census of 14 children, including 5 infants and 9 preschool aged children. According to Title 22 regulations, when 14 children are in care, no more than 3 infants may be present. Based on observations and a review of records, it was determined that the licensee was operating outside the conditions and limitations of the licensed capacity. As a result, a Type A citation is being issued.

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 3 adults living in the facility. Facility Day care hours are 8am-6pm, Monday through Friday.

(continue to page 2)
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
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)
Page: 2 of 8
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: KIM, MONICA
FACILITY NUMBER: 304313626
VISIT DATE: 06/11/2026
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
26
27
28
29
30
31
32
(page 2)

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 baby gates and child proof doorknobs. The child care area consists of the 2 living rooms, a bedroom, one bathroom. The children walk through the hallway to the bathroom. Licensee stated the children's primary area is the living rooms. There are working carbon monoxide, smoke detector, and fire extinguishers 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. There were no poisons or other items observed which could pose a danger to children or 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 inspections. The home has age appropriate toys for the ages served.

During the physical plant inspection, LPA observed a crib containing a sheet with straps attached to its ends. When asked about the item, the licensee explained that it was a type of mattress topper or cover that the infant’s mother requested be used. LPA informed the licensee that crib sheets must be tight fitting and advised the licensee to request a compliant sheet from the parent. Based on this observation, a Type B citation is being issued.

LPA verified there is a working telephone service (cellular service), licensee was reminded that childcare phone needs to remain the in the childcare at all times. Licensee stated they use a section of the backyard for outdoor play, which is fenced. There are no bodies of water on the premises

The licensee does have a current roster of children in care. A sample of 8 Children’s records were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance. LPA reviewed LIC 9227 forms and sleep logs for infants.

(continue to page 3)
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
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: KIM, MONICA
FACILITY NUMBER: 304313626
VISIT DATE: 06/11/2026
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
26
27
28
29
30
31
32
(Page 3)

The licensee’s Pediatric CPR/First Aid certification expires 06/2027, Licensee was reminded to ensure she renews it before expiration 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 pertussis, measles for licensee and assistant were 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 and assistants are exempt from taking the Mandated Reporter training due to training not being available in Korean. Licensee possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires June 2025.

In the areas that were evaluated, 1 Type A and 1 Type B deficiency was observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit. Type A: Staffing Ratio and Capacity 102416.5(d)(1); Type B: Infant Safe Sleep 102425(b). See attached LIC 809D.

LPA Lucero informed Licensee that this report dated 06/11/2026 documents one Type A citation which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Lucero informed facility representative to provide a copy of this licensing report dated 06/11/2026 that documents any Type A citation(s) 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.

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/.
(continue to page 4)
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC809 (FAS) - (06/04)
Page: 4 of 8
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: KIM, MONICA
FACILITY NUMBER: 304313626
VISIT DATE: 06/11/2026
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
26
27
28
29
30
31
32
(Page 4)
The licensee understands she 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

CCLD website www.cdss.ca.gov/inforesources/community-care-licensing is to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee is advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.

Child Care Licensing Safe Sleep: 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.

Licensee is 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.

(continue to page 5)
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC809 (FAS) - (06/04)
Page: 5 of 8
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: KIM, MONICA
FACILITY NUMBER: 304313626
VISIT DATE: 06/11/2026
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
26
27
28
29
30
31
32
(Page 5)

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 Monica Kim 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 Monica Kim.

End of Report.
NAME OF LICENSING PROGRAM MANAGER: Martha Malane
NAME OF LICENSING PROGRAM ANALYST: Giselle Lucero
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2026
LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 06/11/2026 12:28 PM - It Cannot Be Edited


Created By: Giselle Lucero On 06/11/2026 at 11:52 AM
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: KIM, MONICA
FACILITY NUMBER: 304313626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above. There were 14 childeren present at the time of inpsecton; 5 of the children were infants. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2026
Plan of Correction
1
2
3
4
Licensee will send LPA plan to ensure she is within ratio by POC 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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Giselle Lucero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 06/11/2026 12:28 PM - It Cannot Be Edited


Created By: Giselle Lucero On 06/11/2026 at 11:52 AM
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: KIM, MONICA
FACILITY NUMBER: 304313626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/11/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 observaton and interview, the licensee did not comply with the section cited above. There was a crib with a lose sheet. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/12/2026
Plan of Correction
1
2
3
4
Licensee stated she will send statement and plan to LPA to ensure it does not happen again.
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.
Martha Malane
NAME OF LICENSING PROGRAM MANAGER:
Giselle Lucero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2026


LIC809 (FAS) - (06/04)
Page: 8 of 8