Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313606
Report Date: 06/13/2019
Date Signed: 06/13/2019 04:02:41 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:KIM, ANNABELLEFACILITY NUMBER:
304313606
ADMINISTRATOR:KIM, ANNABELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 518-0033
CITY:FULLERTONSTATE: CAZIP CODE:
92833
CAPACITY:14CENSUS: 0DATE:
06/13/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Annabelle KimTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
The pre-licensing inspection conducted in Korean. Licensing Program Analyst (LPA), Han conducted an announced Pre-Licensing inspection of the facility on today's date. Licensing Program Analyst (LPA), Han met with the applicant, Annabelle Kim, for a pre-licensing visit. The licensee moved from previous licensed address at 1034 S. Kingsley Dr. Los Angeles, CA 90006, facility number 198018052.

The LPA toured the facility with the applicant, Annabelle Kim. The facility was clean, orderly, and was at a comfortable temperature. A review of staff criminal clearance 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 or exemptions.

The facility is a single house home with three bedrooms, two bathrooms, living room, kitchen, detached garage, front yard, and backyard that is fenced. The applicant has designated living room, bedroom that is on the right as one enters the front door, bathroom that is on the left as one enters the hallway, and backyard which separately gated are used for childcare. The applicant has designated two bedrooms, kitchen, laundry room, detached garage, and front yard as OFF-LIMIT area. The applicant has placed child proof door handles in order to prevent the children from entering the off-limit rooms in the rest of the home. The applicant acknowledged the children may never enter the off-limit areas. The toys are age appropriate and in good condition for the potential ages served.

The applicant stated that there are no firearms on the premises. The smoke detector, fire extinguisher, and carbon monoxide detector were present and within regulations. The fire alarm and carbon monoxide detector were functioning during today's inspection. Pediatric CPR & First Aid are current for the applicant (exp. 7/2020). Control of property was verified by LPA during today's inspection via the property tax bill. The LPA advised of Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in the children's files.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
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 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: KIM, ANNABELLE
FACILITY NUMBER: 304313606
VISIT DATE: 06/13/2019
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Current immunization information for pertussis, measles, and influenza were verified for the applicant. Proof of mandated reporter training was verified by the LPA.

The LPA advised the applicant to contact licensing for any changes to hours and days of planned operation, and also for any changes to facility, including on/off limit areas and change in phone number. The applicant has a cell phone that is used for child care. The applicant was reminded that if a cell phone is only used, it must remain on the premises at all times during hours of operation.
The applicant stated she will wait until facility opens to determine IMS needs.
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

A Child Care Provider’s Guide to Safe Sleep packet, Safety Seat, Never Ever Shake a Baby information, Lead exposure information and Safe Sleep Regulation concepts which is not regulation yet and its information may change were discussed and provided to the applicant. 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. The below links offer more information on safe sleep to our providers
https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials


LPA reviewed Unusual Incident Report form-advised to contact Licensing Officer of the Day within 24 hours and complete the Unusual Incident Report (LIC 624B) within seven days. LPA reminded the applicant of requirements of disaster drills (documented every 6 months), posting requirements, children records, mandated child abuse and injury/death reporting. LPA advised the applicant of children's rights, including no intimidation, humiliation, and no corporal punishment.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
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: KIM, ANNABELLE
FACILITY NUMBER: 304313606
VISIT DATE: 06/13/2019
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The applicant was also informed to visit the www.ccld.ca.gov website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov
The following were discussed: Individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to being present in the facility. Adults must contact a Live-Scan complete LIC 9163. If adult is fingerprinted cleared and associated to another facility, licensee must complete a Criminal Record Clearances or Exemption Transfer Request form (LIC 9182 or LIC 9188). Contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182 or LIC 9188) with copy of ID and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult. The applicant was informed that the Criminal Record Statement (LIC 508) has been updated, and the facility must now use the new form with revised date. The applicant was also informed that the LIC 508 must be submitted with all Criminal Background Clearance Transfer Request (LIC9182).
The applicant was provided a copy of appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the licensing office within 15 business days.
The facility was in compliance with Title 22 Regulations. LPA informed applicant that a final review of the file will be done before the license is issued. The applicant will be notified if any corrections or additions still need to be completed. Pending review and approval, a small family child care license will be granted.
An exit interview conducted where the report was discussed with the applicant. 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.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jung Mi HanTELEPHONE: (714) 703-2819
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3