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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434413707
Report Date: 08/20/2025
Date Signed: 08/21/2025 01:43:11 PM

Document Has Been Signed on 08/21/2025 01:43 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, KYUNGMIFACILITY NUMBER:
434413707
ADMINISTRATOR/
DIRECTOR:		GU, KYUNGMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 320-2256
CITY:SANTA CLARASTATE: CAZIP CODE:
95050
CAPACITY: 14TOTAL ENROLLED CHILDREN: 13CENSUS: 11DATE:
08/20/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:34 AM
MET WITH:Inyoung Cho, JungHyun Choi, Jaekyung Lim and Kyungmi GuTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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At 09:34AM, Licensing Program Analyst (LPA), Mandeep Kaur conducted an unannounced Annual Random inspection. LPA met with two Assistants, Inyoung Cho and JungHyun Choi and explained to them the nature of today's inspection. Also present in the home were 11 children including three infants. All required posting materials were posted. The daycare is open Monday through Friday from 7:30 AM to 6:00 PM. There are no active waivers or exceptions for this facility.

At 09:41AM, Assistant, Jaekyung Lim arrived.

At 10:01AM, Licensee, Kyungmi Gu arrived at the facility and nature of the inspection was explained to them. Licensee stated that they were at the other center facility in the morning and left the home around 08:40AM this morning.
At 10:29AM, Licensee left the facility to go to other center facility.

At 11:01AM, Licensee arrived at the facility.

At 12:04PM, Licensee left the facility and was present at the facility at 01:15PM, upon LPA's arrival back to the facility.

LPA toured the indoor and outdoor areas of the facility with Assistant, Inyoung Cho. Fire/disaster drill was conducted on June 18, 2025. LPA observed a fully charged fire extinguisher and functioning smoke and carbon monoxide detectors, Licensee was advised to have the fire extinguisher inspected every year by the fire department or receipt needs to be attached to new fire extinguisher every year. Licensee stated that she bought the fire extinguisher end of last year. Licensee states that there are no weapons or firearms in the home.
Continuation on next pages:
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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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: 08/20/2025
NARRATIVE
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Off limit areas of the home are: Storage room (Landlord), Laundry Room, Bedroom , one Bathroom, Closet, Kitchen and Basement. LPA observed that the home is clean and orderly. LPA observed day care children transition through the kitchen to go the outdoor play area. LPA observed three knives in one of the kitchen's unlocked drawer accessible to the children. Licensee was advised to keep cleaning products, sharp objects, and other items that are dangerous to children in to be stored at the place that is inaccessible to the children. During today's inspection, knives were removed and kept at the place where it is inaccessible to the children. LPA observed sufficient age-appropriate materials, toys, and play equipment in the home. The children's bathroom is clean, sanitary, and operable. No bodies of water observed during today's inspection.

LPA reviewed five(5) children files during today's inspection for the following records: Notification of Parents
Rights (LIC995A), Consent for Emergency Medical Treatment (LIC627), Identification and Emergency Information (LIC700), and Immunization Records. Licensee was advised to have infant safe sleep log for every 15 minutes check up for all the infants up to 24 months old and Sample Infant Sleep Observation form was provided during today's inspection. Licensee has current liability insurance on file. Licensee was advised if licensee decides to not to have liability insurance in the future, licensee will have to have Affidavit Regarding Liability Insurance (LIC 282) in each child's file with parents signature. Licensee was advised to have the current immunization records for children in day care home on file.

LPA reviewed three(3) Assistants(S1, S2 & S3) files for the following records: Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Child Abuse (LIC 9108), immunizations, TB test, and required training. Licensee has immunizations in measles, pertussis and flu. Based on records review, staff (S1) does not have immunization( measles, pertussis and flu) in file and staff (S3) does not have measles records in file. Based on records review, one out of three staff's(S1) Criminal background/Fingerprint clearance is not associated to the day care home facility. Based on records review, Staff (S3) and licensee do not have current Mandated Reporter Training(AB1207) on file. Licensee has current Pediatric CPR/First Aid certifications with an expiration date of January 28, 2026. LPA reminded Licensee that Mandated Reporter Training must be renewed by all staff every 2 years. During today's inspection, criminal background clearance transfer request (LIC 9182) was discussed with Licensee and copy is provided.

Healthy Beverage requirements were discussed during today's inspection with Licensee. Licensee was advised to label the each food container and water bottles if brought from home, with children names on it.

Continuation on next pages:
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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: 08/20/2025
NARRATIVE
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LPA provided and discussed the safe sleep regulations with Licensee and discussed the Child Care Licensing Safe Sleep webpage at an additional resource. LPA also reminded Licensee of the importance of checking for recalled infant deviceshttps://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual-
Regulation Interpretations and Procedures for Family Child Care Homes, Section 102417. 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 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: http://www.ada.gov/childqanda.htm

Licensee, Kyungmi Gu, was reminded that all adults 18 and over living in the home, persons who provide
care and supervision to children, and staff who have contact with children, 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address
provided. Please complete the survey and share your inspection experience. If you have any questions
regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional
information regarding the inspection and its tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/process.


Continuation on next page:
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
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: 08/20/2025
NARRATIVE
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Licensee, Kyungmi Gu, 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&R's) throughout California.

During today's inspection, Type B deficiencies issued on attached-809-D. Appeal rights provided.

Exit interview conducted and report was reviewed with Licensee, Kyungmi Gu.
.
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.

A NOTICE OF SITE VISIT WAS ISSUED AND MUST REMAIN POSTED FOR 30 DAYS.
NAME OF LICENSING PROGRAM MANAGER: Belinda Devall
NAME OF LICENSING PROGRAM ANALYST: Mandeep Kaur
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 08/21/2025 01:43 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 08/20/2025 at 02:28 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: GU, KYUNGMI
FACILITY NUMBER: 434413707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

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 , the licensee dobservations, licensee did not comply with the section cited above. LPa observed three knives in a kitchen drawer that is accessible to the children, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2025
Plan of Correction
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Deficiency is cleared during today's inspection and knives were moved to the inaccessible areas of the children.
Type B
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in one staff (S1) out of three staff does not have criminal backgroud clearance associated to the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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By plan of correction due date, 08/27/2025, Licensee will associate staff's(S1) criminal background clearance to the facility.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:
Mandeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2025 01:43 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 08/20/2025 at 02:28 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: GU, KYUNGMI
FACILITY NUMBER: 434413707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
(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 records review, the licensee did not comply with the section cited above. Licensee and staff (S3) do not have current Mandated reporter Training Certificate (AB1207) on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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By Plan of correction due date, 08/27/2025, Licensee will submit the copy of the current Mandated reporter Training (AB1207) certificates for Licensee and staff (S3) to the Department.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:
Mandeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/21/2025 01:43 PM - It Cannot Be Edited


Created By: Mandeep Kaur On 08/20/2025 at 02:28 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: GU, KYUNGMI
FACILITY NUMBER: 434413707

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above. Staff (S1) does not have immunizations in measles, pertussis and flu on file and Staff (S3) does not have Measles records on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/03/2025
Plan of Correction
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By Plan of Correction due date, 09/03/2025, Licensee will submit proof of Immunization records in measles, pertussis and flu for a staff (S1) and Measles records for Staff (S3) to the department.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and records review, the licensee did not comply with the section cited above. Licensee does not have current child care roster with currentlyt enrolled children information on file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2025
Plan of Correction
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By Plan of correction due date, 08/27/25, Licensee will submit the current child care roster with the currently enrolled childre information to the department.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Belinda Devall
NAME OF LICENSING PROGRAM MANAGER:
Mandeep Kaur
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2025


LIC809 (FAS) - (06/04)
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