Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313452
Report Date: 08/31/2018
Date Signed: 08/31/2018 11:39:03 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:MIN, JIFACILITY NUMBER:
304313452
ADMINISTRATOR:MIN, JIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 397-9383
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:14CENSUS: 0DATE:
08/31/2018
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Ji MinTIME COMPLETED:
11:50 AM
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A Pre-licensing visit was made by Licensing Program Analyst (LPA), Jacqueline Moore on this date due to a relocation change previous license number 198917433. Present was licensee, Ji Min who allowed LPA entrance into the home No children were present during today's inspection. LPA toured inside and outside of the home and paperwork was reviewed. Control of property was reviewed and a copy was given to LPA during inspection.
A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances. There are 2 adults and 2 minors living in the home. CPR and First Aid Card will expire 09/2019. Licensee had 8 hours health and safety class certificate including the 1 hour required nutrition class. LPA observed the immunization's of Pertussis and Measles, and the AB 1207 mandated reporter training The Parents' Rights poster and posting requirements are accessible for viewing in the day care room.
This is a two story, 4 bedrooms home with 3 bathrooms with detached garage. with office located over the garage. Licensee has designated the living room, dining room area, bathroom in the downstairs hallway, and fenced backyard for the care and supervision of children. The day care room has a secured gate at the entrance of the day care rooms. The off limit areas included: the entire second story which included three bedrooms and one bathroom. There was no fence or barricade located at the bottom of the staircase, laundry room on the first floor, bedroom and bathroom inside of the bedroom located on the first floor were accessible. The family room which was off limits and made inaccessible by a gate to the entrance of the room, this area also included the kitchen/ dining room areas. There was a fire place located in the living room. LPA observed an air conditioning unit in the backyard of the home in the children's play area that had the top portion of the air condition vent accessible. LPA observed Toys and outside play equipment that appears age appropriate for ages served are located here. The smoke detector, fire extinguisher, and carbon monoxide detector were present and operational condition.

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: Report is continued on Page2/LIC 809C

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2018
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 3
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: MIN, JI
FACILITY NUMBER: 304313452
VISIT DATE: 08/31/2018
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page2/LIC 809C
S 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

Copy of emergency disaster plan, 8 hour health and safety certificate, criminal record statement, required Immunization's of Influenza, Pertussis and Measles, and control of property was given to LPA.

The following were discussed: Individuals who are 18 years of age or older living or working in the home must be fingerprint 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 discussed and 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 submit to the licensing office, 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 and any other item that falls into that category, SIDS, earthquake preparedness(copy given) and, California child passenger safety law (PUB 269 2/18) (copy given). Department web site form was given to down load forms and Title 22 regulations on-line at http://www.ccld.ca.gov ,Child Care Advocate Program childcareadvocatesprogram@dss.ca.gov. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. Quarterly Updates, California Child Passenger Safety Law poster (copy was given), fire and disaster drills are to be completed every 6 months and documented. LPA advised that it is recommended that fire/disaster drills are conducted and documented on a monthly basis. 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. Safe sleep practices and never shake a baby.



Fire clearance from Fullerton Inspection Services was received and approved for requested capacity on 7/20/18.
LPA reviewed with the Licensee per the fire clearance the garage and second story of the home are not approved for daycare in a large family child care home. Licensee stated there are no weapons and/or firearms on the premises. No bodies of water were observed.
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: 08/31/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2018
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: MIN, JI
FACILITY NUMBER: 304313452
VISIT DATE: 08/31/2018
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page 3/ LIC 809C

Based on LPAs observation of the stairs, kitchen entrance from the day care room area, laundry room and bedroom on the first floor will all need to be made inaccessible and the top portion of the air conditioning unit in the backyard of the children's play area was accessible. Licensee will send pictures via email of the corrections to be completed to LPA within 30 days of today's date, LPA will then issue a regular license for a large family child care home. LPA informed the licensee a final review of the file will be done before the license is issued. The licensee will be notified if any corrections or additions still need to be completed. Pending review and approval, a large family child care license will be granted.

Exit interview conducted. Report was reviewed and discussed. Appeal rights were discussed

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2018
LIC809 (FAS) - (06/04)
Page: 3 of 3