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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314489
Report Date: 01/29/2025
Date Signed: 01/29/2025 01:02:06 PM

Document Has Been Signed on 01/29/2025 01:02 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:SHIM, JUYEONFACILITY NUMBER:
304314489
ADMINISTRATOR/
DIRECTOR:		SHIM, JUYEONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(949) 761-0063
CITY:IRVINESTATE: CAZIP CODE:
92602
CAPACITY: 14TOTAL ENROLLED CHILDREN: 11CENSUS: 11DATE:
01/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:05 AM
MET WITH:Licensee, Juyeon ShimTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Page One

On 01/29/2025, Licensing Program Analysts (LPAs), Alma Castro and Christine Jung conducted an unannounced case management-deficiency inspection. Upon arrival, LPA met with licensee, Juyeon Shim. LPA disclosed the purpose of the inspection and was led on a tour of the facility. There were eleven (11) children and five (5) staff, including licensee. Of those eleven (11) children, four (4) were under 24 months. Licensee was operating within the licensed capacity as specified on license.

During record review, LPAs observed incomplete personnel and children’s records. Based on the information obtained and interviews conducted, two Type B citations for Child Records and Personnel Records are being cited on the LIC809D.

Exit interview conducted with Jueyon Shim. Notice of Site Visit (LIC9213) was provided and shall be posted for 30 days.

End of Report

SUPERVISORS NAME: Nguyen K Tran
LICENSING EVALUATOR NAME: Alma Castro
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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 2
Document Has Been Signed on 01/29/2025 01:02 PM - It Cannot Be Edited


Created By: Alma Castro On 01/29/2025 at 12:26 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: SHIM, JUYEON
FACILITY NUMBER: 304314489

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/28/2025
Section Cited
CCR
102421(a)

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102421(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).
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Licensee submitted an LIC855 (Declaration) stating they are surrending their licensee effective today, 01/29/2025.
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Based on observation, interivew and record review, the licensee did not comply with the section cited above. Seven (7) out of eleven (11) children did not have a child record which poses a potential health, safety or personal risk to persons in care.
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Licensee submitted an LIC855 (Declaration) stating they are surrending their licensee effective today, 01/29/2025.
Type B
02/28/2025
Section Cited
CCR102461.1(a)

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102461.1(a) Personnel records shall be maintained on each employee and shall contain the following information.
This requirement was not met as evidenced by:
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Licensee submitted an LIC855 (Declaration) stating they are surrending their licensee effective today, 01/29/2025.
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Based on observation, interivew and record review, the licensee did not comply with the section cited above. Staff 2 (S2), Staff 3 (S3) and Staff 4 (S4) did not have a complete file, which poses a potential health, safety or personal right risk to persons in care.
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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:Alma Castro
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025


LIC809 (FAS) - (06/04)
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