434409311-7-19-2023-07-CC-PHEZ-CTVSEF-20230719134839

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434409311
Report Date: 07/19/2023
Date Signed: 07/19/2023 01:49:02 PM

Document Has Been Signed on 07/19/2023 01:49 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-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME:	PARK, MIKYONG		FACILITY NUMBER:	434409311
ADMINISTRATOR:	PARK, MIKYONG		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 873-1685
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95129
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 5	DATE:	07/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Mikyong Park		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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 (5) (2 infant and 3 preschool aged) and explained the purpose for today’s inspection. Licensee lives with her husband Jiwon Park. 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 7/3/2023. 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 between the living room and the rest of the home. 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 5 children's files and Licensee's file observed the required documentation in the files . REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 07/19/2023

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PARK, MIKYONG	FACILITY NUMBER: 434409311
	VISIT DATE: 07/19/2023

NARRATIVE

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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 07/19/2023):

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: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: PARK, MIKYONG	FACILITY NUMBER: 434409311
	VISIT DATE: 07/19/2023

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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.

Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT 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 was 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: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023

LIC809 (FAS) - (06/04)

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