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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 444414178
Report Date: 08/11/2026
Date Signed: 08/11/2026 10:06:24 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/28/2026 and conducted by Evaluator Andy Yang
COMPLAINT CONTROL NUMBER: 07-CC-20260728151309
FACILITY NAME:KIM, NICOLEFACILITY NUMBER:
444414178
ADMINISTRATOR:KIM, NICOLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 332-9872
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY:14CENSUS: 9DATE:
08/11/2026
UNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Nicole KimTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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Other - A child wandered away from the facility.
INVESTIGATION FINDINGS:
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On 8/11/2026, Licensing Program Analyst (LPA) Andy Yang conducted an unannounced complaint investigation. LPA met with Licensee, Nicole Kim and discussed the complaint allegation with them, and to deliver the complaint allegation listed above. Present for today’s investigation were Licensee (2) staff and (9) children. LPA toured the indoor areas of the facility with Licensee.

LPA conducted interview with the Licensee and witness, and received copy of the incident report.

The allegation stated that a child wandered away from the facility. It was reported that on 7/28/2026 that child C1 was found by a witness who had gotten out from the day care home. Licensee had self-reported the incident to the department on 7/28/2026, and a police report from the Scotts Valley Police Department was received dated 7/28/2026. Based on the evidence received, C1 was left unsupervised resulting C1 wandering away from the facility.
***Continue Page 2***

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Adam Hamer
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 07-CC-20260728151309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: KIM, NICOLE
FACILITY NUMBER: 444414178
VISIT DATE: 08/11/2026
NARRATIVE
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***Page 2***

Based on LPA’s interviews and supporting documents gathered, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED California Code of Regulations, 102417(a), and Type A deficiency is issued on attached LIC 9099D.

LPA Andy Yang informed licensee, Nicole Kim, that this report dated 8/11/2026 document a 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 Andy Yang informed the licensee to provide a copy of this licensing report dated 8/11/2026 that documents any Type A citation 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.

An immediate civil penalty of $500 is hereby assessed for the day of 8/11/2026 (refer to LIC421IM).


A notice of site visit was given and must remain posted for 30 days. Appeal Rights provided.

Exit interview conducted and report was reviewed with the Licensee, Nicole Kim.
SUPERVISORS NAME: Adam Hamer
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 07-CC-20260728151309
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: KIM, NICOLE
FACILITY NUMBER: 444414178
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2026
Section Cited
CCR
102417(a)
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102417 Operation of a Family Child Care Home (a) The licensee shall be present in the home and shall ensure that children in care are supervised at all times...
This requirement was not met as evidence by
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By plan of correction dated 8/12/2026, Licensee will submit a written supervision plan describing how children will be supervised and accounted for at all times.
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Child C1 had an unsupervised absence from the facility, where C1 had wandered away from the home. The allegation was confirmed through the licensee’s admission on 7/28/26, and the Scotts Valley Police Department's police report dated 7/28/26. This poses an immediate risk to the Health, Safety or Personal Rights risk to children in care.
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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: Adam Hamer
LICENSING EVALUATOR NAME: Andy Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3