<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417021
Report Date: 04/24/2023
Date Signed: 04/24/2023 10:55:16 AM

Document Has Been Signed on 04/24/2023 10:55 AM - 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: 11CENSUS: 8DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Jiae KimTIME COMPLETED:
11:15 AM
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) Mel Matos met with Jiae Kim, Licensee, for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. Note: main entrance to the day care is via the side backyard gate facing Heron Ave. LPA also observed two adult assistants (Mi Hong & Yong Kyo Cho), and eight day care children (3 infants & 5 preschool) in the home during today's inspection. Licensee was operating within her capacity and ratio requirements. LPA observed the required postings, including the facility license, near the main entrance to the day care. Days and hours of operation are Monday - Friday from 8:00 AM to 5:00 PM. The adults that reside in the home and are the Licensee, Licensee's mother, Mi Hong, and Licensee's brother, Hyo Kim. There are no minor children residing in the home.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on February 10, 2023. Licensee has liability insurance for the day care through State National Insurance Co, Inc. Licensee has current CPR and First Aid certifications (expiration: 05/2023). Licensee and her two adult assistants has the required vaccines (MMR, Tdap, & flu) and are current with her Mandated Reporter Training for Child Care Workers. LPA reviewed six children's files and the files were complete with the required forms. LPA reviewed three staff files (Licensee & two adult assistants) and the files were complete with the required forms. Licensee states that a child will be isolated in the family room area of the home if necessary due to illness or communicable disease.

LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home. The home is clean, orderly, (including central heating/air conditioning/ventilation), and safe for the day care children. There are safe and age appropriate toys, play equipment, and materials for the children in the home. LPA did not observe any wall heaters units or stairs inside the home. There are no stairs, wall heater units, or fireplace units in the home. Off limit areas indoors are: Bedroom 1 & 2, one bathroom, living room, kitchen, and attached garage. Off limit areas outdoors: right side area of the home. There is a play structure in the backyard area that is safe/secure for children. There are also sufficient resilient materials (rubber tiles & artificial grass) underneath and surrounding the play structure.

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, no bodies of water, and fenced backyard. The Licensee states that she does not have any pets or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are stored inaccessible to children. Any poisons are locked and inaccessible to the day care children.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Melvin S Matos
LICENSING EVALUATOR SIGNATURE: DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: KIM, JIAE
FACILITY NUMBER: 434417021
VISIT DATE: 04/24/2023
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
26
27
28
29
30
31
32
Licensee states that she provides meals (snacks and lunch) to the day care children. Licensee understands that any food brought from home shall be labeled with each child's name and properly stored. Licensee has a first aid kit in the home which includes a touch less thermometer. Licensee understands that smoking is prohibited in the home.

Licensee states that she does not administer any medications to the day care children at this time. 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 (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: http://www.ada.gov/childqanda.htm

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. Licensee understands her capacity/ratio options and she understands that she cannot have more than 14 children present in the home without at least two qualified adults present. Licensee states that does not transport any day care children. Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with the 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 the 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.

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

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: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2