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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416065
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:07:37 PM

Document Has Been Signed on 08/16/2023 03:07 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:KIM, KYUNGSOOKFACILITY NUMBER:
354416065
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 4DATE:
08/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Kyungsook KimTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Kyungsook Kim for a required one year visit and increase of capacity. LPA explained the nature of today’s inspection to her. Present were licensee, licensee's adult daughter and four day care children including two infants. Days and hours of operation are Monday to Friday, 8:00am to 5:00pm. The adults that reside in the home are licensee and adult daughter.

A review of staff records on 08/02/2023 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee Kyungksook Kim was reminded that all adults 18 and over living or working in the home, 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 licensed Family Child Care 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.

LPA toured the indoor and outdoor areas of the home during today’s inspection. LPA observed that the home is clean and orderly, with heating and ventilation for safety and comfort of the children. LPA observed and infant in a play yard wrapped in a blanket. LPA observed a changing table with several items in it including blankets and a towel hanging over sleeping infant and a mobile attached to play yard. LPA observed and additional mattress was placed in play yard. LPA observed a child sleeping on the couch in the living room. LPA observed barricaded stairs in the home. LPA observed safe and sufficient materials, toys, and play equipment for the day care children. All sharp objects, detergents, cleaning compounds, medications, poisons, and other similar items inside the home are stored inaccessible to children. LPA observed a fully charged 3A40BC fire extinguisher, a working smoke and carbon monoxide detector. Licensee states there are no weapons/firearms in the home. Off limit areas indoor: upstairs master bedroom/bath, three bedrooms, one bathroom and downstairs attached garage and storage under

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIM, KYUNGSOOK
FACILITY NUMBER: 354416065
VISIT DATE: 08/16/2023
NARRATIVE
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staircase. LPA observed water table with approximately three inches of water and a small trash can filled to the top with water. Backyard is fenced. Off limits outdoor: area behind fenced off area of patio. Licensee states she has one dog and two cats in the home that are vaccinated. LPA observed licensee has a current CPR and First Aid certification expiring 03/05/2024 and completed Mandated Reporter training.

LPA observed a current roster of the children and a fire and disaster drill log which was last completed on 03/06/2023. LPA reviewed five children's files. Child 5 is missing LIC9227. Licensee did not have a Safe Sleep Log for all infants in care. All children have current immunization records. Licensee states day care is not insured. LPA observed LIC282 in children's files. LPA discussed SB792 Immunization Requirements and observed licensee has immunization records on file.



Supervision of children was discussed with licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity options and she understands that she cannot have more than eight children in the home at any time. Licensee understands if she transports children via vehicle, children cannot be left in parked vehicles unattended at any time.

LPA discussed the safe sleep regulations with licensee Kyungsook Kim 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 Kyungsook Kim 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.


LPA discussed Zero Tolerance related regulations with licensee Kyungsook Kim and was advised of the assessment of $500 immediate civil penalty and an ongoing $100 per day per violation continues until the violation(s) is corrected. 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
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
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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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIM, KYUNGSOOK
FACILITY NUMBER: 354416065
VISIT DATE: 08/16/2023
NARRATIVE
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To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Exit interview conducted and report was reviewed with the licensee Kyungsook Kim. During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Licensee was informed that an informal meeting will be required to discuss her increase of capacity.

The following type A and B deficiencies were cited on the attached page (809-D). Licensee was informed that failure to correct the deficiencies by the specified Plan of Correction (POC) Due Date may result in assessment of civil penalties in the amount of $100 per day per violation until the correction is made.

LPA Deanna Villagrana informed licensee Kyungsook Kim that this report dated 08/16/2023 document(s) 3 Type A citation(s) 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 Deanna Villagrana informed the licensee Kyungsook Kim to provide a copy of this licensing report dated 08/16/2023 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.

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.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023
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Document Has Been Signed on 08/16/2023 03:07 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 08/16/2023 at 02:30 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KIM, KYUNGSOOK
FACILITY NUMBER: 354416065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above. LPA observed an infant in a play yard wrapped in a blanket which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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Licensee removed blanket during visit. Licensee will submit a statement that she has read Safe Sleep Regulations.
Type A
Section Cited
CCR
102425(b)(3)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects. (3) There shall be no objects hanging above or attached to the side of the crib.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a changing table with several items in it including blankets and a towel hanging over sleeping infant and a mobile attached to play yard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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Licensee removed items during visit. Licensee will submit a statement that she has read Safe Sleep Regulations.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2023 03:07 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 08/16/2023 at 02:30 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KIM, KYUNGSOOK
FACILITY NUMBER: 354416065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(5)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed water table with approximately three inches of water and a small trash can filled to the top with water which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2023
Plan of Correction
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Licensee removed water during visit. A Civil Penalty of $500 is being assessed for a Zero Tolerance violation.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2023 03:07 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 08/16/2023 at 02:30 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KIM, KYUNGSOOK
FACILITY NUMBER: 354416065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(a)(3)
Infant Safe Sleep
(a) There shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard. (3) Mattresses shall be firm and covered with a fitted sheet that is appropriate to the mattress size, fits tightly on the mattress, and overlaps the underside of the mattress so it cannot be dislodged.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed and additional mattress was placed in play yard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2023
Plan of Correction
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Licensee removed mattress during visit. Licensee will submit a statement that she has read Safe Sleep Regulations.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. Child 5 is missing LIC9227 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Licensee will submit LIC9227 for child 5 to CCLD by POC date.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/16/2023 03:07 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 08/16/2023 at 02:30 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KIM, KYUNGSOOK
FACILITY NUMBER: 354416065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Licensee did not have a Safe Sleep Log for all infants in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Licensee will submit a Safe Sleep log for all infants in care for week of 08/21/2023-08/25/2023 to CCLD by POC date.
Type B
Section Cited
CCR
102423(a)(2)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following: (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a child sleeping on the couch in the living room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2023
Plan of Correction
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Licensee will submit a statement stating she understands all children shall receive comfortable accommodations to avoid potential safety risk to children in care.
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:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023


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