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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624420
Report Date: 09/06/2022
Date Signed: 09/06/2022 11:15:23 AM

Document Has Been Signed on 09/06/2022 11:15 AM - 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:KIM, HYO JINFACILITY NUMBER:
343624420
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Hyo Jin KimTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Fabiola Diaz conducted a pre-licensing inspection with applicant, Hyo Jin Kim. Applicant's adult daughter was present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance.

A health and safety inspection was conducted inside and out the home. The home has 3 bedrooms, 2 bathrooms, a kitchen, a living room, dining room, a laundry closet, garage, and fenced front patio and backyard. The off-limit areas in the home are entire upstairs, garage, fenced right side of backyard, and kitchen. LPA advised the applicant that if there are ever any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA observed the home to provide safe toys, play equipment and materials for the day care children. LPA observed a barricaded fireplace and stairs.

Toxic and hazardous items are inaccessible to children. LPA observed functioning smoke and carbon monoxide detectors. LPA observed a 2A-10B-C fire extinguisher in the home. A working telephone was observed. Applicant stated there are no weapons in the home. Current EMSA approved pediatric CPR and First Aid training was verified and expires 6/4/24. Applicant's CA AB1207 Mandated Reporter Training expires 5/24/24. Applicant completed the 8 hour Preventative Health and Safety Training with the Lead Poisoning Prevention training.

Page 1. Report Continues on LIC 809-C...
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Fabiola Diaz
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: KIM, HYO JIN
FACILITY NUMBER: 343624420
VISIT DATE: 09/06/2022
NARRATIVE
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

Records, postings and reporting requirements were discussed. LIC311D was provided and discussed. Applicant was encouraged to visit the department website at WWW.CDSS.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes. LPA provided and discussed the Safe Sleep in Child Care Regulations (and provided a copy). LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list. childcareadvocatesprogram@dss.ca.gov.

Applicant was encouraged to maintain supervision at all times. LPA discussed requirements for staff, adult assistants, and adults living in the home. LPA discussed the new Immunization Regulations SB 792, the requirement that all individuals working or volunteering at a licensed Child Care Home must have vaccinations against Pertussis, Measles, and Influenza (Influenza is optional). LPA observed proof of applicant's immunization in the facility file. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed. Applicant understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

Page 2. Report Continues on LIC 809-C...
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Fabiola Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: KIM, HYO JIN
FACILITY NUMBER: 343624420
VISIT DATE: 09/06/2022
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Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA explained to applicant that if she relocates and wants to continue to provide care, she must submit a change of location application and have the new home inspected.

Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if they want to make any off-limit area an ON-limits area, they must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. Applicant understands that children’s records are to be maintained according to Title 22 regulations, and be accessible to licensing for up to three years.

On today's date 9/6/22 the facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

An exit interview was conducted. Appeal Rights and Notice of Site Visit were provided. The Notice of Site Visit must remain posted for 30 days.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Fabiola Diaz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022
LIC809 (FAS) - (06/04)
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