434413707-5-9-2024-07-CC-MKAR-D54TJY-20240509144706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 434413707
Report Date: 05/09/2024
Date Signed: 05/09/2024 02:47:28 PM

Document Has Been Signed on 05/09/2024 02:47 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:	GU, KYUNGMI		FACILITY NUMBER:	434413707
ADMINISTRATOR/ DIRECTOR:	GU, KYUNGMI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 320-2256
CITY:	SANTA CLARA	STATE: CA	ZIP CODE:	95050
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 11	CENSUS: 11	DATE:	05/09/2024
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Kyungmi Gu		TIME VISIT/ INSPECTION COMPLETED:	03:10 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), Mandeep Kaur conducted an unannounced Annual/Random inspection. LPA met with Licensee, Kyungmi Gu explained the reason for the inspection. Present during today's inspection were Licensee, Eleven (11) Children , and two assistants. The hours of operation are Monday through Friday 08:30AM to 5:30PM. There is a board to post required postings, such as license and notification of parent's rights. LPA toured the inside and outside of the home with Licensee. The off-limits areas inside are Private room, Kitchen, Laundry room and one bedroom. Outside offlimit area is storage. Disinfectant and cleaning supplies were inaccessible to children. LPA reminded licensee that anything sharp or states to keep out of reach of children, such as blades or razors need to be inaccessible. There are age appropriate toys and equipment for children inside and outside of the home. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire/disaster drill was conducted on April 24, 2024. Licensee stated that there are no weapons, such as firearm, stored in the home. The backyard is used for the play. Licensee stated that provides morning snacks, lunch, and afternoon snacks to the children. LPA discussed the beverages requirements provided by the providers to the children. -----------------CONTINUES ON 809 DATED 05/09/2024 PAGE 2-----------------

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GU, KYUNGMI	FACILITY NUMBER: 434413707
	VISIT DATE: 05/09/2024

NARRATIVE

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--------------CONTINUATION OF 809 DATED 05/09/2024 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. LPA also discussed that either licensee or an assistant needs to be present in the infant nap room during an infant is taking a nap.

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/.

LPA reviewed four (4) children's files during today's inspection. The records reviewed include but not limited to immunization records and notification of parent's rights.

LPA reviewed 2 staff files. Statement Acknowledging Requirement to Report Child Abuse,TB Clearance and Immunizations (Measles, Pertussis, and Influenza) and required training. LPA reminded Licensee that the Mandated Reporter Training shall be renewed by all staff every two years. At least one staff member present during the inspection has current Pediatric CPR/First Aid certifications.

Licensee completed the Mandated Reporter training on 08/13/2022. Licensee has a valid CPR/1st Aid, which
expires on 01/2026.

----------------CONTINUES ON 809 DATED 05/09/2024 PAGE 3----------------

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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 CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: GU, KYUNGMI	FACILITY NUMBER: 434413707
	VISIT DATE: 05/09/2024

NARRATIVE

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--------------CONTINUATION OF 809 DATED 05/09/2024 PAGE 2-------------

The adults 18 and over living in the home are Licensee and her husband. All adults have cleared criminal record and child abuse index. 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.

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.

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

As a result of this inspection, No Citations were issued.

Exit interview conducted and report was reviewed with Licensee, Kyungmi Gu. A notice of site visit has been issued and must remain posted for 30 days.

SUPERVISORS NAME: Belinda Devall
LICENSING EVALUATOR NAME: Mandeep Kaur
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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