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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313606
Report Date: 08/13/2021
Date Signed: 08/13/2021 11:51:26 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:KIM, ANNABELLEFACILITY NUMBER:
304313606
ADMINISTRATOR:KIM, ANNABELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(213) 514-2282
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:14CENSUS: 2DATE:
08/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Annabelle Kim, Licensee TIME COMPLETED:
11:50 AM
NARRATIVE
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On 08/13/2021, A required-1 Year inspection was conducted at the facility by Licensing Program Analysts (LPA) Tran and LPA Quinto. LPAs observed licensee Annabelle Kim, caring for 1 infant in the day care area. At approximately 9am, another infant was brought to the home. Licensee was operating within the licensed capacity as specified on license.

A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Facility Day care hours are 8am-6pm, Monday through Friday.

During today’s inspection, LPAs and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. The facility is a single house home with three bedrooms, two bathrooms, living room, kitchen, detached garage, front yard, and backyard that is fenced. Off limits areas are made inaccessible by the security gate. Family member residing at facility is 1 adult and no children. The children walk through the hallway to the bathroom. Licensee stated the children's primary area is the childcare room. There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are not firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. The home has age appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service). Licensee stated they use an outdoor play area. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible.

The licensee DOES have a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance.)

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 703-2841
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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 5
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: KIM, ANNABELLE
FACILITY NUMBER: 304313606
VISIT DATE: 08/13/2021
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LPA observed 1 infant from 0-12 months. As reviewed the infant's file at 9:10am, LIC 9227 and Sleeping Log were not available in file for review. When asked, Licensee reported that child does not take nap here at the day care therefore Licensee did not think she would need the form.

The Licensee's Pediatric CPR/First Aid certification was not available to verify at the time of the inspection, however, Licensee provided an email proof that she has taken the course in August 2020. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. Proof of immunization against pertussis, measles for licensee were reviewed and within compliance.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years. The licensee is exempt from this requirement due to the training not being available in Korean.

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 licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 703-2841
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
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: KIM, ANNABELLE
FACILITY NUMBER: 304313606
VISIT DATE: 08/13/2021
NARRATIVE
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CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
LPA reviewed with licensee the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used if they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.

The facility was not in compliance and violations of the California Code of Regulations, Title 22, Division 12 were observed, discussed and cited at the time of the visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Personnel Requirements 102416(c), Infant Safe Sleep 102425(c) and 102425(j)(2)(D). Please see LIC 809D.

An exit interview was conducted with Licensee Annabelle Kim. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

End of Report.
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 703-2841
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: KIM, ANNABELLE
FACILITY NUMBER: 304313606
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2021
Section Cited

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102416 Personnel Requirements
(c) The licensee ... shall complete training ... on including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met evidenced by:
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Based on interview and record review, Licensee did not have the Pediatric CPR and First Aid certification at the time of the inspection, which posts potential risks to the health and safety of the children in care.
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Type B
08/13/2021
Section Cited

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102425 Infant Safe Sleep (c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age ... included in the infant's file at the facility ... and be ready for the Department for review.
This requirement is not met as evidenced by:
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Base on interview and record review, Licensee did not have the form LIC 9227 available at the time of the inspection.
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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: Thuy HoTELEPHONE: (714) 703-2841
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: KIM, ANNABELLE
FACILITY NUMBER: 304313606
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2021
Section Cited

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102425 Infant Safe Sleep (j)(2)(D) Documentation shall be maintained in the infant’s file ... include the following:
• CCR 102425(j)(2)(D)(a) Date
• CCR 102425(j)(2)(D)(b) Infant's name
• CCR 102425(j)(2)(D)(c) Time of each 15-minute check
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This requirement is not met, evidenced by:
Base on interview and record review, Licensee did not have the Sleeping Log available at the time of the inspection.
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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: Thuy HoTELEPHONE: (714) 703-2841
LICENSING EVALUATOR NAME: Nguyen K TranTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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