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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416065
Report Date: 09/05/2023
Date Signed: 01/26/2024 05:59:36 PM

Document Has Been Signed on 01/26/2024 05:59 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
SAN JOSE CC RO, 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: 8CENSUS: 0DATE:
09/05/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kyungsook KimTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Deanna Villagrana and Licensing Program Manager (LPM) Joel Segura conducted a scheduled office meeting at the San Jose Regional Office with Licensee Kyungsook Kim to discuss their request for increase of capacity and citations issued including three type A citations since obtaining their license.

On 08/16/2023, LPA conducted a required visit to the home. LPA observed an infant in a play yard wrapped in a blanket, a changing table with several items in it including blankets and a towel hanging over sleeping infant and a mobile attached to play yard, a water table with approximately three inches of water and a small trash can filled to the top with water, no Safe Sleep log for infant, infant missing LIC9227 and a child sleeping on a couch. Licensee has corrected cited deficiencies since time of the visit.

LPM Joel Segura, explained that if there are continued serious deficiencies cited against the facility including but not limited to citations for Personal Rights, Ratio and Operation of a Family Child Care Home, the license may be referred to legal for possible administrative action, which could include revocation of the facility license. The facility will be monitored more frequently to ensure that the facility is maintaining compliance with Title 22 regulations, at discretion of the agency. At this time approval for an increase of capacity is under review due to deficiencies. Licensee may apply again in 6 months if they have demonstrated substantial compliance with Title 22 Regulations. Licensee provided a hand written statement stating they are withdrawing their increase of capacity application at this time.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2023
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIM, KYUNGSOOK
FACILITY NUMBER: 354416065
VISIT DATE: 09/05/2023
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LPM Joel Segura discussed the requirements of AB 633 with Kyungsook Kim and provided her with the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and she understands the requirements.
Copies of this report must be provided to parents/guardians of children currently in care at this Facility and to parents/guardians of children newly enrolled at this Facility during the next 12 months.
SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC809 (FAS) - (06/04)
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