Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313452
Report Date: 05/09/2019
Date Signed: 05/09/2019 04:25:14 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:MIN, JIFACILITY NUMBER:
304313452
ADMINISTRATOR:MIN, JIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 397-9383
CITY:FULLERTONSTATE: CAZIP CODE:
92835
CAPACITY:14CENSUS: 11DATE:
05/09/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Ji MinTIME COMPLETED:
04:35 PM
NARRATIVE
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An inspection was conducted at the facility by Licensing Program Analyst (LPA) Stacy Torrence. 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.

According to licensee, there are presently two adults and two children living in the home. During today’s inspection the home was toured, and the licensee was operating within the licensed capacity. Present during today's inspection was the Licensee, Ji Min and Assistant Jia Byeon. There were 11 napping children present today. Licensee currently have 12 children enrolled. Current children’s roster was available. This is a two-story home which consists of four bedrooms, three bathrooms, living room, family room, kitchen, dining room, front yard, back yard, and garage. The floor plan was verified. Living room and dining is used as the main daycare area. Off limit areas include: entire upstairs, garage, and front yard. Licensee provide food for the children in care. The licensee's pediatric CPR/First Aid certification are current; however, her assistant has not completed her CPR/First Aid. Items which could pose a danger to children were not accessible to children. Poisonous items were not observed during today's inspection. The smoke detector and carbon monoxide were tested and are operable. Fire extinguisher is fully charged. Emergency Disaster drill log within the past six months was available. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's visit. Children's records: parents' rights and California School Immunization Record were reviewed. C #1 and C#2 were missing proof of immunization.

Incidental Medical Services-IMS was discussed. For IMS information see Evaluator Manual- Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417. 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
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SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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: MIN, JI
FACILITY NUMBER: 304313452
VISIT DATE: 05/09/2019
NARRATIVE
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Licensee had proof of immunization against Pertussis, Measles, and Influenza; however, her assistant did not have proof of immunization.

Facility was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov . LPA assistant Licensee on signing up to receive Quarterly Updates. A copy of the 2016 “A Child Care Providers Guild to Safe Sleep”.

H&S 1596.8662: Commencing January 1, 2018 all the licensed providers, applicants, directors and employees are required to complete training as specified on the mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training. AB1207 Mandated Child Abuse Reporting – Implementation was discussed with Licensee. Website provided: http://mandatedreporterca.com/. Licensee’s assistant has not completed the mandated child abuse reporting training. LPA advised Licensee to provide the department with a copy of the certificates; once completed.


There were deficiencies cited per CA Code of Title 22, Division 22, see 809-D page.

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. Licensee was informed how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.

END OF REPORT
SUPERVISOR'S NAME: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
LIC809 (FAS) - (06/04)
Page: 3 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: MIN, JI
FACILITY NUMBER: 304313452
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2019
Section Cited
HSC
1597.622(a)(1)
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1597.622(a)(1)Employees or volunteers at family day care home; immunization requirements; records; exemptions. Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or
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Per Licensee, she will have her staff obtain proof of immunizations and maintain a copy on file. A copy of the immunization record will be submitted to LPA by POC due date.
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she has not been immunized against influenza, pertussis, and measles.Each employee and volunteer shall receive an influenza vaccination between A ugust 1 and December 1 of each year. The requirement is not met as evidence by record review of Assistant. Assistant is missing proof of Pertussis, Measles, and Influenza vaccine. This poses a potential risk to the health of children in care.
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Type B
05/31/2019
Section Cited
CCR
102416(c)
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102416(c) Personnel Requirements. The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidence by Assistant has not
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Per Licensee, she will have her assistant complete the required Pedriatric First Aid and CPR and submit a copy to LPA by POC due date.
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completed the required Pediatric First Aid and CPR. This poses a potential risk to the safety of 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
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: MIN, JI
FACILITY NUMBER: 304313452
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2019
Section Cited
CCR
102418(a)
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102418(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000. The requirement is not met as evidence by record review of C #1 and C#2 is missing proof of immunization. This poses a potential risk
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Per Licensee, she will obtain proof of immunizations and maintain a copy on file. A copy of the immunization record will be submitted to LPA by POC due date.
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to the health of 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: Rina LopezTELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 703-2823
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4