Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312243
Report Date: 04/19/2018
Date Signed: 04/19/2018 11:25:53 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:LEE, KYUNG AEFACILITY NUMBER:
304312243
ADMINISTRATOR:LEE, KYUNG AEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 562-0886
CITY:BUENA PARKSTATE: CAZIP CODE:
90621
CAPACITY:14CENSUS: 8DATE:
04/19/2018
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Kyung LeeTIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analysts(LPAs), Moore and Han were greeted by licensee Kyung Lee and allowed entrance into the facility. LPAs observed 2 infants and 6 preschool children in one of the day care rooms being supervised by 2 adult assistants, Nam Yeon Kwon and Yoon Park. A review of adult individuals living or working in this facility on this date who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are 2 adult living in the facility. Today's inspection was translated in the Korean language by LPA Han to the licensee.

LPAs toured the home inside and outside with the licensee. This is two story home with 4 bedrooms and 3 bathrooms. The licensee has designated the off limit areas of the day care home which included : the entire entire second floor which was gated at the bottom of the stairs, attached garage, kitchen/dining room area which had a child safety lock on the entrance to the kitchen.
The licensee has designated the following areas for day care children which included: The day care rooms to the left and right of the entrance of the facility, The down stairs bathroom was inspected for proper storage of all cleaning compounds, medications, perfumes, shampoos, toothpaste, and sharp pointed objects. The enclosed fenced backyard was used for outdoor play.

There were no wall heaters observed, the fireplace in the day care room to the right of the entrance of the facility was barricaded with book shelves. The bottom of the stairs had a secured gate. LPAs discussed with the licensee that children were not allowed to be in the second floor of the home nor in the garage. Licensee stated understands. Per the licensee there are no weapons are firearms in the facility. LPAs did not observe any bodies of water at the facility.
Furniture and equipment was inspected for age appropriateness and good repair. Telephone service, heating, lighting and ventilation were evaluated. The home was equipped with a 2A:10BC Fire Extinguisher, smoke detector, and carbon monoxide detector which were in working condition.
Report is continued on page 2 ( LIC 809C)
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2018
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 4
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: LEE, KYUNG AE
FACILITY NUMBER: 304312243
VISIT DATE: 04/19/2018
NARRATIVE
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Page 2/ LIC 809C

EMSA Pediatric CPR & First Aid card for licensee was observed and will expire on 5/18. LIcensee'a adult assistant Nam Yeon Kwon also had current CPR and First Aid that will expire 5/2018. Licensee and adult assistants were exempt from having the mandated reporter training certificates on file, due to licensee and assistants primary language is Korean. The licensee and the 2 adult assistants did not have the required immunization's on file for Pertussis, Measles, and Influenza. The licensee stated that she did not know about the immunization's.
LPAs reviewed children's files for immunization record and parent right's notification. LPAs reviewed fire drill/disaster drill log. Children's roster was reviewed and LPA took photos of the children's roster.

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
The following were discussed: Individuals who are 18 years of age or older living in the home must be finger print cleared prior to presence in the facility. No smoking in the areas accessible to the day care children, 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), All areas/ rooms that are off-limits need to be made inaccessible during operating hours, no infant walkers, Johnny jumpers, Exersaucers, Bouncers and any other item that falls into that category, SIDS and Never Shake a Baby (Copy given), Quarterly updates, Child Care Advocate Program childcareadvocatesprogram@dss.ca.gov.



Report is continued on Page 3/ LIC 809C
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2018
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: LEE, KYUNG AE
FACILITY NUMBER: 304312243
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2018
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/21/2018
Section Cited
HSC
1597.622
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Employee and Volunteer Immunization: (a) (1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination
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The licensee says she will fix this deficiency by having the Measles, Influenza, and Pertussis immunization's completed and will send a copy to LPA via email by due date of 5/21/18.
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between August 1 and December 1 of each year. Licensee and 2 adult assistant's did not have Measles, Influenza, Pertussis immunization's on file for review during today's inspection.
This may pose a potential health and safety 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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2018
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2018
LIC809 (FAS) - (06/04)
Page: 4 of 4
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: LEE, KYUNG AE
FACILITY NUMBER: 304312243
VISIT DATE: 04/19/2018
NARRATIVE
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Page 3/ LIC 809C

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., Centralized Complaint and Information Bureau(copy given), California child passenger safety law (PUB 269) (copy given), SB 792, and earthquake preparedness

In the areas evaluated during today's inspection, a deficiency was observed. discussed and cited. The facility was not incompliance with CA Code of Regulations, Title 22, and Division 12 at the time of todays' inspection.

Exit Interview conducted with the licensee. Report was reviewed and discussed.



The licensee was provided a copy of their appeal rights and their signature on this form acknowledges receipt of these rights. The first level appeal is to Regional Manager, address is above on the report. 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. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 04/19/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2018
LIC809 (FAS) - (06/04)
Page: 3 of 4