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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409311
Report Date: 09/05/2024
Date Signed: 09/05/2024 04:04:52 PM

Document Has Been Signed on 09/05/2024 04:04 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:PARK, MIKYONGFACILITY NUMBER:
434409311
ADMINISTRATOR/
DIRECTOR:		PARK, MIKYONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 873-1685
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 7DATE:
09/05/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Mikyong ParkTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Annual/Random inspection. LPA met with Licensee Mikyong Park and explained the reason for the inspection. Present during today's inspection were Licensee, her spouse, and seven children, whom four were infant age.

LPA toured the inside and outside of the home. The off-limit areas of the home are the master room, bath 1, bedroom 1, bedroom 2, garage, and kitchen. LPA observed that the kitchen is accessible to children and there is no barricade or gate. LPA observed that there was a medicines in one the drawers that is next to the dining table. LPA did not observe any children going in to the kitchen area during today's inspection. LPA also observed that there were creams and hair dye in the bathroom that was accessible to children. Licensee removed medicines, hair dye, and creams during today's inspection. LPA discussed with Licensee that anything that states to keep out of reach of children or medication needs to be inaccessible to children. There are no stairs or fireplace in the home. There are toys for children. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on 05/03/2024. Licensee stated that there are no weapons, such as firearms stored on the premise.

The backyard is fenced. Licensee that she is currently not using the backyard, but understands that the fence that leads to the right and left side of the yard needs to be placed to make it inaccessible to children. There were no bodies of water observed during today's inspection.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2024
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: PARK, MIKYONG
FACILITY NUMBER: 434409311
VISIT DATE: 09/05/2024
NARRATIVE
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------------CONTINUATION OF 809 DATED 09/05/2024 PAGE 1-----------------

LPA discussed the safe sleep regulations with licensee 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 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. Upon entrance into the home, there was an infant asleep in a car seat. LPA discussed with Licensee that car seats can only be used for transportation. LPA also discussed with Licensee that she needs to conduct 15 minutes sleep check when infants are asleep and document the name of the child, date, and the time checked. Licensee stated that she has not documented the time, name of the child, and date. PIN 20-24-CCP was provided to Licensee during today's inspection.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee only provides snack to children. Meals are prepared and brought from home. Licensee does not transport children, but understands that children cannot be left alone and unattended in parked vehicles.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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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: 09/05/2024
NARRATIVE
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--------------CONTINUATION OF 809 DATED 09/05/2024 PAGE 2--------------

Seven children's files were reviewed during today's inspection. The records reviewed include but not limited to immunization records and LIC 627: Consent for Emergency Medical Treatment. C-1 and C-2 were missing signature on the LIC 627.

Licensee has a valid CPR/1st Aid, which expires on 12/2025. Licensee and her spouse have not completed the Mandated Reporter training. LPA discussed with Licensee that the Mandated Reporter training is required for anyone who is working with children and requires renewal every two years. The mandated reporter training can be completed at mandatedreporterca.com. Licensee has immunization records for measles and pertussis. Licensee will obtain her spouse's and send proof to Licensing.

The adults living in the home are Licensee and her spouse. All adults have cleared criminal record, child abuse index, and TB test. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During the exit interview, the Licensee, Mikyong Park, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

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SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
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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: 09/05/2024
NARRATIVE
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-----------CONTINUATION OF 809 DATED 09/05/2024 PAGE 3------------

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

An updated LIC 279 was obtained during today's inspection.

Licensee will submit the following:
- Mandated Reporter training certificate by 10/22/2024
- immunization records for spouse
- sleep check log for infants

As a result of this inspection, Type B citations were issued. Exit interview conducted and report was reviewed with Licensee Mikyong Park. A notice of site visit has been issued and must remain posted for 30 days.
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2024 04:04 PM - It Cannot Be Edited


Created By: Samantha Yip On 09/05/2024 at 03:25 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: PARK, MIKYONG
FACILITY NUMBER: 434409311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)
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: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children.

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, which poses a potential health, safety or personal rights risk to persons in care. There were hair dye and creams in the bathroom that stated to keep out of reach of children. There is a drawer in the kitchen that has medication.
POC Due Date: 09/12/2024
Plan of Correction
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Licensee removed hair dye and creams in the bathroom and the medication in the kitchen during today's inspection.
Type B
Section Cited
CCR
102425(h)
Infant Safe Sleep
Car seats shall only be used for transportation purposes and shall not be used for sleeping.

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 in one out of four persons, which poses a potential health, safety or personal rights risk to persons in care. Upon arrival, there was an infant asleep in the car seat.
POC Due Date: 09/12/2024
Plan of Correction
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By POC 09/12/2024, Licensee will submit written statement that she understands that car seats can only be used for transportation and that infants cannot sleep in car seats.
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:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


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Document Has Been Signed on 09/05/2024 04:04 PM - It Cannot Be Edited


Created By: Samantha Yip On 09/05/2024 at 03:25 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: PARK, MIKYONG
FACILITY NUMBER: 434409311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

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 in two out of two persons, which poses a potential health, safety or personal rights risk to persons in care. Licensee and her spouse has not completed Mandated Reporter training.
POC Due Date: 10/22/2024
Plan of Correction
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By POC 10/22/2024, Licensee and her spouse will complete Mandated Reporter training and submit proof to Licensing.
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 interview, the licensee did not comply with the section cited above in four out of four persons, which poses a potential health, safety or personal rights risk to persons in care. Licensee does not document the name of the child, date, and the time checked.
POC Due Date: 09/12/2024
Plan of Correction
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By POC 09/12/2024, Licensee will complete sleep check and document the name of the child, date, and time checked when infants are sleeping. Licensee will submit proof to Licensing.
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:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2024


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