Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304206891
Report Date: 09/27/2019
Date Signed: 09/27/2019 04:03:03 PM

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: 10DATE:
09/27/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mary KeumTIME COMPLETED:
04:20 PM
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An unannounced annual inspection was conducted at the facility by Licensing Program Analyst (LPA) Stacy Torrence. LPA met with Mary Keum, who guided analyst on a tour of the Early Childhood Setting indoors and outdoors. Licensee's husband was also present. Licensee’s sister-in law arrived shortly after LPA's arrival. During today’s inspection, there was 10 children present. Licensee has a current children’s roster available. Licensee states that three adults live in the home. Operation hours are 8:00 a.m. to 6:00 p.m.; Monday through Friday. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

This is a single-story home which consist of three bedrooms, two bathrooms, living room, den, kitchen, garage, front yard (not fenced), and back yard (fenced). Licensee stated that OFF LIMITS areas include: the bedrooms, garage and kitchen. Licensee acknowledged that children may never enter these off-limit areas. The areas the licensee has designated for the day care children included the living room, den, and one bathroom.

The daycare area was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning supplies, medication, and hazardous items that can pose a danger to children. Per licensee there are no weapons or firearms in the facility. There were age appropriate toys and learning materials. Fire/disaster drill log was reviewed. Outdoor play activity is in the enclosed front yard and occasionally the back yard(fenced). Licensee stated that she is always present when children are outside playing. The required fire extinguisher (2A10BC), smoke detector, and carbon monoxide detector were in operable condition. First Aid kit was complete. Licensee had a current CPR/First Aid card which will expire (05/20) and EMSA certified. Children's records were reviewed.
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019
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: 09/27/2019
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Licensee has proof of immunization against pertussis, measles, and influenza. Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov. Licensee is not required to complete the mandated reporter training, as it is not in their first language (Korean). However, Licensee does understand English without an interpreter. Licensee was informed how/where to access regulations and forms from CCLD website: www.ccld.ca.gov. LPA provided licensee with the Effects of Lead Exposure handout.

During this inspection, there was no deficiency cited in accordance with California Code of Regulations, Title 22, Division 12.

Exit interview was conducted. Report reviewed and discussed with the licensee. 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. Appeal rights provided and explained. The licensee was provided a copy of their appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. First level appeal is to Regional Manager, address is above on the report.

SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2019
LIC809 (FAS) - (06/04)
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