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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417288
Report Date: 01/16/2024
Date Signed: 01/16/2024 04:10:13 PM

Document Has Been Signed on 01/16/2024 04:10 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:SONG, JISOOFACILITY NUMBER:
434417288
ADMINISTRATOR:SONG, JISOOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 710-6765
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
01/16/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Jisoo SongTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced Required- 3 Year inspection. LPA met with Assistant, Youjeong Kim, and explained the reason for the inspection. Upon arrival, LPA observed that there were three assistants and 8 children. A-1 has cleared criminal records, but fingerprints were not transferred. A-2 and A-3 have not completed fingerprints. Licensee was reminded that all adults 18 and over, 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 Child Care Center. 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. Licensee, her own child, who is infant age, and her relative, Sookyoung Kim, who was helping translate, arrived shortly after.

There is board to post required postings, such as license and notification of parent's rights. The hours of operation are Monday through Friday 9AM to 6PM. Licensee does have liability insurance.

LPA toured the inside and outside of the home with Licensee and her relative. The off-limit areas of the home are the kitchen, master room, R1, R2, R3, and the garage. There was only a gate leading to the kitchen on the dining room. LPA discussed with Licensee's relative that all off-limit areas need to be inaccessible. Licensee's relative placed a gate to make the kitchen inaccessible

---------------CONTINUES ON 809 DATED 01/16/2024 PAGE 2---------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2024
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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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: SONG, JISOO
FACILITY NUMBER: 434417288
VISIT DATE: 01/16/2024
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----------------CONTINUATION OF 809 DATED 01/16/2023 PAGE 1-----------

from the family room during today's inspection. The fireplace in the home was barricaded. There are toys and equipment for children. There is a fully charged fire extinguisher, smoke detector, and carbon monoxide detector. The last fire drill was conducted on 10/19/2023. There are no weapons, such as firearms, stored in the home. Licensee does not transport children.

The backyard is used and is fenced. There is a swing set and a play structure that are anchored to the ground. There were no bodies of water observed during today's inspection.

LPA discussed the safe sleep regulations with 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 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

-----------------CONTINUES ON 809 DATED 01/16/2024 PAGE 3-----------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SONG, JISOO
FACILITY NUMBER: 434417288
VISIT DATE: 01/16/2024
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-----------------CONTINUATION OF 809 DATED 01/16/2024 PAGE 2----------

A copy of the facility roster was obtained during today's inspection. Seven children's files were reviewed during today's inspection. The records reviewed include but not limited to parent's rights.

Licensee and her assistant's files were reviewed. Licensee and A-1 have a valid CPR/1st Aid. Licensee's CPR/1st Aid expires on 07/23/2025 and A-1's expires on 09/2024. None of the staff have Mandated Reporter training certificate on file.

The adults living the home are Licensee and her spouse. Licensee also has two minor children. All adults living in the home have cleared criminal record, child abuse index, and TB.

During the exit interview, the Licensee's relative, Sookyoung Kim, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

As a result of this inspection, two Type A and two Type B citation was issued. A civil penalty of $1,500 was assessed for caregiver background check. Exit interview conducted and report was reviewed with Licensee's relative, Sookyoung Kim, who helped translate. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Licensee's relative, Sookyoung Kim, that this report dated 01/16/2024 document(s) two Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Licensee to provide a copy of this licensing report dated 01/16/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/16/2024 04:10 PM - It Cannot Be Edited


Created By: Samantha Yip On 01/16/2024 at 03:26 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: SONG, JISOO
FACILITY NUMBER: 434417288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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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3
4
Based on record review, the licensee did not comply with the section cited above in, which poses an immediate health, safety or personal rights risk to persons in care. A-2 and A-3 have not obtain criminal record clearance prior to initial presence.
POC Due Date: 01/17/2024
Plan of Correction
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By POC 01/17/2024, Licensee will have A-2 and A-3 obtain fingerprints and understands that they cannot return until their fingerprints are cleared.
Type A
Section Cited
CCR
102370(d)(2)
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Request a transfer of a criminal record clearance...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. A-1 has cleared criminal record, but fingerprints were not transferred.
POC Due Date: 01/17/2024
Plan of Correction
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By POC 01/17/2024, Licensee will submit LIC 9182 and understands that A-1 cannot return until her fingerprints are transferred.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 01/16/2024 04:10 PM - It Cannot Be Edited


Created By: Samantha Yip On 01/16/2024 at 03:26 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: SONG, JISOO
FACILITY NUMBER: 434417288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/16/2024

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 observation, the licensee did not comply with the section cited above, which posed a potential health, safety or personal rights risk to persons in care. LPA observed that there was a bottle of toilet bowl cleaner under the sink the bathroom and knives in the kitchen.
POC Due Date: 01/23/2024
Plan of Correction
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Deficiency cleared during today's inspection. Licensee's relative moved toilet bowl cleaner to an off-limit room and placed a gate to make the kitchen inaccesssible.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(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 record review, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. Licensee and her assistants do not have Mandated Reporter training on file.
POC Due Date: 03/04/2024
Plan of Correction
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By POC 03/04/2024, Licensee and her assistant will complete Mandated Reporter training and send certificate to Licensing.
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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2024


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