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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409311
Report Date: 06/08/2022
Date Signed: 06/08/2022 11:29:27 AM

Document Has Been Signed on 06/08/2022 11:29 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PARK, MIKYONGFACILITY NUMBER:
434409311
ADMINISTRATOR:PARK, MIKYONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 873-1685
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 14TOTAL ENROLLED CHILDREN: 6CENSUS: 6DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Mikyong ParkTIME COMPLETED:
11:57 PM
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Licensing Program Analyst (LPA) Pete Hernandez conducted an Required 1 Year visit to the home today. LPA met with Mikyong Park who was caring for six (6) (2 infant and 4 preschool aged) and explained the purpose for today’s inspection. Licensee lives with her husband Jiwon Park. Also present was her mother Shincha Lee. Licensee is the homeowner and resides in the house with her husband. They each have fingerprint clearance. Days and hours of operation are Monday through Friday 7:30 AM to 5:00 PM. Licensee's CPR and First Aid card is current and expires on 12/2023. LPA observed all the required posting near the front door.
LPA toured the indoor and outdoor (on and off limits) areas of the home. LPA observed a fire drill log with the last fire drill being conducted in 1/4/2021. LPA reviewed a current facility roster. LPA observed a working fire extinguisher (3A40BC) , smoke detectors, carbon monoxide detectors and fire pull stations. The Licensee has a working telephone in the home. LPA observe a barricaded fireplace in the day care area. Off limit areas in the home: master bedroom & bathroom, a bedroom, home office, kitchen and garage. There are no stairs in the home other than split level. Off limit areas outside the home: 2 side yards.. License stated that when outside the children are supervised by herself. LPA observed no bodies of water. The Licensee states that she does not have any firearms or other weapons in the home. All poisons, detergents, cleaning supplies, medications, and other similar items are inaccessible to children.
LPA reviewed 6 children's files and Licensee's file observed the required documentation in the files EXCEPT 5 of 6 files were missing immunization documentation.
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REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 06/8/2022
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/08/2022
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PARK, MIKYONG
FACILITY NUMBER: 434409311
VISIT DATE: 06/08/2022
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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 08/03/2021):
Licensee has the required immunization's against Pertussis, Measles and influenza on file for herself. Supervision of children was discussed with the Licensee. Licensee stated she is present in the home 100 percent of the hours the day care is in operation and ensures that the children are supervised at all times. The Licensee understands her capacity options. The Licensee stated that she does not transport children via vehicle. Licensee understands the seat belt/car seat laws and that children cannot be left in parked vehicles unattended at any time.

A review of Staff records indicates that all persons that require a caregiver background check have received criminal record and child abuse index clearance or exemption. LPA informed Licensee of the applicable civil penalties for any adult who has not received fingerprint clearances, is not associated to the license and who comes in contact with or provides care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12- month period.

LPA discussed the requirements of AB 633 with the Applicant (or Licensee) and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant (Licensee) understands the requirements.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. 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. The Mandated Reporter Training (AB1207) can be completed at the website listed, http://www.mandatedreporterca.com English is a second language for Licensee. Mandated Reporter is not required at this time.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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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: PARK, MIKYONG
FACILITY NUMBER: 434409311
VISIT DATE: 06/08/2022
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LPA Discussed the Individual Infant Sleep Plan with the Licensee form 9227.

Licensee also provided a current copy of the Children's Roster.

A deficiency is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, An exit interview was conducted, A copy of this report and appeals rights were discussed and left with the Licensee, Mikyong Park, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/08/2022 11:29 AM - It Cannot Be Edited


Created By: Pietro Hernandez On 06/08/2022 at 10:57 AM
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: PARK, MIKYONG
FACILITY NUMBER: 434409311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs review of the files Child 1 through Child 5 the files did not have the immunization records and do not have a completed immunization records PM 286 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2022
Plan of Correction
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BY POC DUE DATE Licensee will obtain updated immunization records for C1 through C5 and send a copy to the Licensing Office as proof of correction.
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs review of the files Child 1 through Child 5 the files did not have the immunization records and do not have a completed immunization records PM 286 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2022
Plan of Correction
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BY POC DUE DATE Licensee will obtain updated immunization records for C1 through C5 and send a copy to the Licensing Office as proof of correction.
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:Joel Segura
LICENSING EVALUATOR NAME:Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022


LIC809 (FAS) - (06/04)
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