Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304206891
Report Date: 05/05/2017
Date Signed: 05/05/2017 10:42:58 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KEUM, MARYFACILITY NUMBER:
304206891
ADMINISTRATOR:KEUM, MARYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 525-7870
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:14CENSUS: 11DATE:
05/05/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Mary KeumTIME COMPLETED:
10:55 AM
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(2) Licensing Program Analyst (LPA), Jacqueline Moore, met with licensee, Mary Keum. LPA was greeted and allowed entrance into the facility by licensee. The census included 6 day care children, whom were all preschoolers and were playing in the front day care room upon LPA's arrival. 5 Additional preschool children arrived during today's inspection. Licensee's husband was present and not assisting with the day care. Adult assistant, arrived at the home shortly after LPA's arrival. A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are 5 adults living in the facility.

Licensee stated that OFF LIMITS areas include: the bedrooms, garage and kitchen. Licensee acknowledged that children may never enter these off-limit areas.

The day-care area was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medication, and hazardous items that can pose a danger to children. Per licensee there are no weapons or firearms in the home. No bodies of water were observed. The home had no fireplace. There are age appropriate toys and equipment for ages served. Fire/disaster drill log was reviewed. Copy of the children's roster was given to LPA during inspection.
Outdoor play area is the back yard. LPA reviewed with licensee that children must be 100% visually supervised when not in a gated or enclosed area, there are safe and age appropriate toys for children to use. The required fire extinguisher (2A10BC), smoke detector, and carbon monoxide detector were in operable condition. Licensee, had current CPR/First Aid cards which will expire (05/18) and EMSA certified.
Staff #1 and #2 had the required immunization's of Pertussis and Measles on file during today's inspection.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KEUM, MARY
FACILITY NUMBER: 304206891
VISIT DATE: 05/05/2017
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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

LPA reviewed areas accessible to day care children, which included, the front and back day care rooms, hallway bathroom, and enclosed back yard. The areas that were evaluated, no deficiencies were observed at the time of the visit. The facility was found to be in compliance with Title 22 regulations.

The following were discussed: Individuals who are 18 years of age or older living in the home must be fingerprint cleared prior to presence in the facility. No smoking, disaster drills, posting requirements, children records, mandated child abuse and injury/death reporting. LPA reviewed Unusual Incident Report form (advised to contact Licensing Officer of the Day within 24 hours and complete the Unusual Incident Report (LIC 624) within 7 days), and criminal records clearances/exemption transfer requests (contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182) and (LIC 508) with copy of ID to fax# (714)703-2831 prior to hiring staff), SIDS and Never Shake a Baby(Copy given), Quarterly updates, SB 792(copy was given) Complaint and information Bureau (copy was given)The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf


Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative. English: https//www.cdph.ca.gov/programs/SIDS/Doucments/SIDSchildcaresafesleep.pdf.

An exit interview was conducted. Report was reviewed and discussed. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. The Notice of Site Visit was posted. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. LPA informed the licensee of how to access regulations and forms from CCLD websites. This report is to be on file and accessible for public review at the facility for at least 3 years.

SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2017
LIC809 (FAS) - (06/04)
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