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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434415417
Report Date: 07/29/2021
Date Signed: 07/29/2021 02:05:39 PM

Document Has Been Signed on 07/29/2021 02:05 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KEEUMFACILITY NUMBER:
434415417
ADMINISTRATOR:HEE SUNG KIMFACILITY TYPE:
850
ADDRESS:2478 WEST EL CAMINO REALTELEPHONE:
(650) 646-1341
CITY:MOUNTAIN VIEWSTATE: CAZIP CODE:
94040
CAPACITY: 42TOTAL ENROLLED CHILDREN: 0CENSUS: 30DATE:
07/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Hee Sung KimTIME COMPLETED:
02:20 PM
NARRATIVE
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On 7/29/21 at 10:18am, Licensing Program Analyst (LPA) B. Plumboy met with Director Hee Sung Kim for another purpose which resulted in a case management inspection. Present for this inspection was 7 fingerprint clear and associated staff as well as 30 children in care. At 12:34pm, LPA Plumboy observed a roach present at the facility.
See 809-D for deficiency cited today. A notice of site visit was given and must remain posted for 30 days. Appeal Rights were given and discussed. An exit interview was conducted.
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Briana Plumboy
LICENSING EVALUATOR SIGNATURE: DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/29/2021
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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Document Has Been Signed on 07/29/2021 02:05 PM - It Cannot Be Edited


Created By: Briana Plumboy On 07/29/2021 at 01:35 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KEEUM
FACILITY NUMBER: 434415417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/06/2021
Section Cited
CCR
101238(a)(1)

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101238(a)(1) Buildings and Grounds. The licensee shall take measures to keep the center free of flies, other insects and rodents.
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On or before 08/06/21, the facility stated they will contact a pest control company/exterminator to come spray the facility. Licensee will send a reciept to LPA Plumboy via fax, text, email, or post.
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This requirement was not met as evidenced by:
Based on observation, at 12:34pm LPA Plumboy observed a roach in the facility and informed the center director. Insects in the facility poses a potential health and safety risk to children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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.
SUPERVISOR'S NAME:Wynn Norona
LICENSING EVALUATOR NAME:Briana Plumboy
LICENSING EVALUATOR SIGNATURE:
DATE: 07/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/29/2021


LIC809 (FAS) - (06/04)
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