343624420-10-9-2024-03-CC-LPEZ-D9VTXA-20241009150649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343624420
Report Date: 10/09/2024
Date Signed: 10/09/2024 03:06:57 PM

Document Has Been Signed on 10/09/2024 03:06 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	KIM, HYO		FACILITY NUMBER:	343624420
ADMINISTRATOR/ DIRECTOR:	KIM, HYO		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 482-5588
CITY:	ANTELOPE	STATE: CA	ZIP CODE:	95843
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 6	DATE:	10/09/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:30 PM
MET WITH:	An Young		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Loraine Perez met with, Licensee Hyo Kim (Licensee), for an unannounced inspection. LPA arrived at the facility at approximately 1:30 PM. Present in the home was one Assistant providing care for six children, three infants and three preschool age children. Licensee arrived later at 2:15 PM. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are Monday through Friday 7:30 AM to 5:30 PM.

A health and safety inspection was conducted in the areas accessible to children. Off limit areas include the entire second floor, kitchen, garage and right sideyard. Licensee understands that children may never enter off-limits areas. LPA observed a working telephone, functioning smoke and carbon monoxide detector, and a 2A10BC fire extinguisher within the home. LPA observed the home was safe, orderly, and free of hazards. LPA observed a variety of age-appropriate toys. Licensee stated there are no firearms or bodies of water on the premises. Licensee stated there are no poisons within the home. Licensee understands that if there are any poisons in the home, all poisons must be locked with a key lock or combination lock. LPA observed all required postings, a children's roster, and fire drill log. LPA reviewed records of children’s files, all of which contained the required documentation.

Licensee and Assistant have current EMSA-approved pediatric CPR/First Aid which expires 06/2026. Licensee has Mandated Reporter certification which expires 05/2026. LPA did not observe current Mandated Reporter Training on file at time of inspection for the Assistant, this is a potential risk to the children in care. Beginning January 1, 2018, Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Licensee understands both CPR and Mandated Reporter training must be completed every two years.

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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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Document Has Been Signed on 10/09/2024 03:06 PM - It Cannot Be Edited

Created By: Loraine Perez On 10/09/2024 at 02:44 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KIM, HYO	FACILITY NUMBER: 343624420
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above, the assistant does not have current mandated reporter certificate of completion, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/08/2024
	Plan of Correction
1 2 3 4	Licensee agrees to send by email to LPA L. Perez (loraine.perez@dss.ca.gov) the Asssistant's mandated reporter certificate of completion.

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.

SUPERVISOR'S NAME:

Amanda Blesi

LICENSING EVALUATOR NAME:

Loraine Perez

LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KIM, HYO	FACILITY NUMBER: 343624420
	VISIT DATE: 10/09/2024

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Licensee was 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.

LPA reviewed with Licensee the safe sleep regulations and the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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. 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.

In the areas that were evaluated, one deficiency was observed at the time of the visit and cited on LIC 809D. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Hyo Kim.

SUPERVISORS NAME: Amanda Blesi
LICENSING EVALUATOR NAME: Loraine Perez
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024

LIC809 (FAS) - (06/04)

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