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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417021
Report Date: 01/17/2024
Date Signed: 01/17/2024 03:56:32 PM

Document Has Been Signed on 01/17/2024 03:56 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: 12CENSUS: 10DATE:
01/17/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jiae KimTIME COMPLETED:
04:20 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 10 preschool children, Mi Hong (Licensee's mother & adult assistant), and Yongkyo Cho (adult assistant) in the home during today's inspection.

LPA reviewed two staff files (adult assistants) and observed that both staff files were complete with the required paperwork.

LPA reminded Licensee that all areas underneath and surrounding the swing area of the play structure must have cushioned material underneath if the swing area is going to be used by the day care children.

Licensee states that she understands LPA's explanation.

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: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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