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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416065
Report Date: 02/09/2024
Date Signed: 02/09/2024 03:59:23 PM

Document Has Been Signed on 02/09/2024 03:59 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
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: 8CENSUS: 3DATE:
02/09/2024
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Kyungsook KimTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA), Elizabeth Larios, met with Licensee, Kyungsook (Rebecca) Kim, to conduct case management visit for capacity increase to a large family child care home (FCCH). Upon arrival, LPA was admitted into the home by Rebecca and toured both indoors and outdoors during today's inspection.

Fire clearance was approved for the home by Hollister Fire Department on 7/31/2023. The Licensee states that adults, over the age of 18, residing in the home is herself. Off-limits inside the home include: entire second floor, and garage. All other areas in the home will remain on-limits and unchanged from the small family child care home limitations. The home is equipped with a 2A10BC fire extinguisher (last serviced 07/2023) functioning smoke detector and carbon monoxide detector. The last emergency disaster drill was conducted on 1/4/2024. There are sufficient toys and materials that are age-appropriate and safe for children.

LPA toured outside of the home and observed it is fenced in for children. Off-limits outside of the home include: the flower beds in backyard. Shade is provided for the children by home building overhang and outside the children have plastic play structures to play with. There were no bodies of water observed during today's inspection.

LPA reviewed large FCCH capacity with the Licensee, Rebecca, and she understands that whenever an assistant is not present, she shall follow capacity requirements for a small FCCH. LPA advised that a large FCCH may care for more than 12 children and up to and including 14 children if at least one child is enrolled in and attending kindergarten or elementary school and a second child is at least six years of age. LPA provided the Licensee with large FCCH capacity reference sheet as well as copy of Section 102416.5 Staffing Ratio and Capacity. LPA advised that an assistant must be older than 14 years old and shall have all required documentation on file such as proof of immunization's (MMR, Tdap, flu), negative tuberculosis (TB) test, Mandated Reporter training for child care providers, and all Licensing paperwork in file.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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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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: 02/09/2024
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If an assistant is older than 18 years old, the assistant must receive Criminal Record Clearance through DOJ, FBI, and CACI within 30 days of turning 18. LPA additionally advised an assistant under the age of 18 shall not be left alone with day care children at any time. LPA advised an assistant over the age of 18 shall remain alone with the children, however must have proof of pediatric First-Aid/CPR.

As a result of today's inspection, no deficiencies were cited.

Exit interview conducted and report was reviewed with the Licensee, Kyungsook (Rebecca) Kim.

LPA advised that a license for a large FCCH will be issued following manager review and approval.

A NOTICE OF SITE VISIT HAS BEEN GIVEN AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Elizabeth Larios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024
LIC809 (FAS) - (06/04)
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