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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314281
Report Date: 01/03/2025
Date Signed: 01/03/2025 12:19:55 PM

Document Has Been Signed on 01/03/2025 12:19 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:PARK, MINAMFACILITY NUMBER:
304314281
ADMINISTRATOR/
DIRECTOR:		PARK, MINAMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 722-1136
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
01/03/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Park, Minam (Licensee)TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 1/3/2025 , an unannounced inspection was conducted at the facility by Licensing Program Analyst (LPA) Vivian Trinh. At 9:00 A.M observed licensee and assistant An, Dongsil caring for total 3 of children, which included 2 infants, 1 preschool were eating morning snack. The licensee was operating within the licensed capacity as specified on license.

Licensee stated she is not currently registered with any Foster Care agency or holds a foster parent license. Licensee was reminded if changes are made to notify the licensing office. Facility Day care hours are 8:00 AM - 5:00 PM, Monday through Friday.

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.

All areas on the Facility Sketch LIC 999 were inspected, including but not limited to, off-limits areas. The facility is a 1 story house with 4 bedrooms, 2 bathrooms, a living room, a kitchen, a laundry room, a front yard (not fenced), and a backyard with a wall, and garage. There is a fireplace, located in the living room, got cover by the children’s toys-self. There area no stair in this home

Garage will not be used for day-care. The licensee stated the garage will be off limit.

The licensee acknowledged the children may never enter the off-limit areas during operation hours. The licensee has a cell phone that is used for childcare. The licensee was informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation.

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SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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 6
Document Has Been Signed on 01/03/2025 12:19 PM - It Cannot Be Edited


Created By: Vivian Trinh On 01/03/2025 at 10:44 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: PARK, MINAM
FACILITY NUMBER: 304314281

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, iinterview, record review, the licensee did not comply with the section cited above, Staff #1 (S1) admitted that Staff #2 (S2) does not have Immunization, and provide evidence of a tuberculosis (T/B) result, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Staff #1 (S1) stated will send copy of Immunization, and TB test results from Staff #2 (S2) to LPA by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nguyen K Tran
LICENSING EVALUATOR NAME:Vivian Trinh
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


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: PARK, MINAM
FACILITY NUMBER: 304314281
VISIT DATE: 01/03/2025
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The licensee was informed and understands the home is to be free from smoking during hours of operation.

Areas Designated for Day Care Activities: The Licensee have designated the living room, and room number 1 on the left-hand side is a nap room for day-care children. children’s bathroom located in the hallway (right hand side), some part of the backyard as the day care areas, with fence/walls. The front yard has no fence . The Licensee stated that parents and children will enter the front door.



There is a fireplace, located in the living room that is made inaccessible to children when in care with glass door cover. During today’s inspection, LPA observed the fireplace was made inaccessible to children in care. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Poisons and Hazardous items were not observed. There are no bodies of water.

The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. Licensee stated there are no weapons or firearms on the premises. When firearms are present, they must be locked and stored separately from the ammunition.

During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged. Fire/disaster drill has been conducted within 6 months. The last fire/disaster was conduct 10/17/2024.

OUTDOOR PLAY AREA: During the pre-licensing inspection the Licensee stated that she will be using one part the backyard as an area of day-care. LPA observed age-appropriate play equipment to be free from hazards. There are no bodies of water, and pets on the premises.

The licensee stated she provides morning, lunch and afternoon snacks to day-care children. The licensee was informed that if children bring food from home, the children’s names must be labeled on their lunch bags and refrigerated/stored properly.

Continued Page 3.

SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
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: PARK, MINAM
FACILITY NUMBER: 304314281
VISIT DATE: 01/03/2025
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Licensee stated that the home is free from smoking during hours of operation. Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen are all inaccessible by child safety locks. Poisons/Hazardous items are not stored on-site, and none were observed.

Per the licensee, children will nap in the room numbers 1 and Living room. Children will nap on cots and infants in cribs/play yards. The licensee understands that there shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.

The licensee stated that parents will provide linens and parents will provide blankets for napping. The licensee stated that parents will provide diapers, lotion, wipes, and formula for the infants. The blankets will be sent home to be washed weekly and as needed for infants. LPA advised the applicant to always supervise at all times infants when changing their diapers.



Licensee has a current (EMSA approved) Pediatric First Aid and Pediatric CPR certification that expires on 4/2026. A first aid kit is available at the facility located inside the closet near the entrance. The licensee has completed the required mandated reporter training. Recertification is required every two years. Licensee AB1207 mandated reporter certification is current, dated 4/7/26.

The licensee does have a current roster of children in care of 3 children records for children present during the LPA inspection time. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700), 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. Licensee stated, there is 2 infant under 24 months enrolled in the childcare. LPA reviewed LIC 9227 Individual Infant Sleeping Plan and napping log for infants.

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 was reviewed and within compliance.
Continued Page 4.
SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
Page: 4 of 6
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: PARK, MINAM
FACILITY NUMBER: 304314281
VISIT DATE: 01/03/2025
NARRATIVE
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Based on the Record Reviewed and interviewed that Staff #2 (S2) does not have proof of immunization against pertussis, and measles, influenza, and provide evidence of a tuberculosis (T/B) test result.

LPA advised the licensee how to access forms, regulations and quarterly updates online at: www.ccld.ca.gov

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.

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/.

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.



Licensee was reminded that all adults 18 and over, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a Child Care Family Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Continued Page 5.

SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
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: PARK, MINAM
FACILITY NUMBER: 304314281
VISIT DATE: 01/03/2025
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Fire clearance granted on October 2, 2024

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Administration of Child Day Care Licensing (HSC) 1597.622 (c) (see LIC 809D).

Exit interview conducted and report was reviewed with the licensee Park Minam. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

During the exit interview on 1/3/2025, the licensee Park, Minam, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

End of Report.

SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Vivian Trinh
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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