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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417021
Report Date: 09/28/2022
Date Signed: 09/28/2022 03:44:52 PM

Document Has Been Signed on 09/28/2022 03:44 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:KIM, JIAEFACILITY NUMBER:
434417021
ADMINISTRATOR:JIAE KIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 503-8542
CITY:SUNNYVALESTATE: CAZIP CODE:
94087
CAPACITY: 14TOTAL ENROLLED CHILDREN: 3CENSUS: 3DATE:
09/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Jiae KimTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Mel Matos met with Jiae Kim, Licensee, for an unannounced case management inspection. LPA also observed three infant children in the home during today's inspection.

LPA reviewed three children's files and the Child Care Facility Roster during today's inspection. All three children's files were complete with all required forms. The Child Care Facility Roster was complete and current.

LPA reminded Licensee of the required paperwork that she will need to have on file for any qualified adult(s) working in the home.

Exit interview conducted and report was reviewed with the Licensee, Jiae Kim. No deficiencies issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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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