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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434409311
Report Date: 08/03/2021
Date Signed: 08/03/2021 02:01:27 PM

Document Has Been Signed on 08/03/2021 02:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:PARK, MIKYONGFACILITY NUMBER:
434409311
ADMINISTRATOR:PARK, MIKYONGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 873-1685
CITY:SAN JOSESTATE: CAZIP CODE:
95129
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 7DATE:
08/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Mikyong ParkTIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Pete Hernandez conducted an Required 1 Year visit to the home today. LPA met with Mikyong Parki who was caring for five (7) napping children (one infant and 6 preschool aged) and explained the purpose for today’s inspection. Also Present was her husband Jiwon Park. Licensee is the homeowner and resides in the house with her husband. They each have fingerprint clearance. Days and hours of operation are Monday through Friday 7:30 AM to 6:00 PM. Licensee's CPR and First Aid card is current and expires on 12/2021. LPA observed all the required posting near the front door.
LPA toured the indoor and outdoor (on and off limits) areas of the home. LPA observed a fire drill log with the last fire drill being conducted in 3/29/2021. LPA reviewed a current facility roster. LPA observed a working fire extinguisher, smoke detectors, carbon monoxide detectors and fire pull stations. The Licensee has a working telephone in the home. LPA observe a barricaded fireplace in the day care area. Off limit areas in the home: master bedroom & bathroom, a bedroom, home office, kitchen and garage. There are no stairs in the home other than split level. Off limit areas outside the home: 2 side yards.. License stated that when outside the children are supervised by herself and at least one other helper. LPA observed no bodies of water. The Licensee states that she does not have any firearms or other weapons in the home. All poisons, detergents, cleaning supplies, medications, and other similar items are inaccessible to children.
LPA reviewed 4 children's files and observed the required documentation.
REPORT CONTINUED ON THE FOLLOWING PAGE (REPORT DATED 078/03/2021):



SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PARK, MIKYONG
FACILITY NUMBER: 434409311
VISIT DATE: 08/03/2021
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CONTINUATION OF PREVIOUS PAGE (REPORT DATED 08/03/2021):
Licensee has the required immunization's against Pertussis, Measles and influenza on file for herself and her assistant Darlene. Supervision of children was discussed with the Licensee. Licensee stated she is present in the home 100 percent of the hours the day care is in operation and ensures that the children are supervised at all times. The Licensee understands her capacity options. The Licensee stated that she does not transport children via vehicle. Licensee understands the seat belt/car seat laws and that children cannot be left in parked vehicles unattended at any time.

A review of Staff records indicates that all persons that require a caregiver background check have received criminal record and child abuse index clearance or exemption. LPA informed Licensee of the applicable civil penalties for any adult who has not received fingerprint clearances, is not associated to the license and who comes in contact with or provides care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12- month period.

LPA discussed the requirements of AB 633 with the Applicant (or Licensee) and provided her the AB 633 fact sheet and a copy of Acknowledgement of Receipt of Licensing Reports (LIC 9224) and Applicant (Licensee) understands the requirements.

LPA provided the Community Care Licensing’s website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, childcareadvocatesprogram@dss.ca.gov. The Mandated Reporter Training (AB1207) can be completed at the website listed, http://www.mandatedreporterca.com English is a second language for Licensee. Mandated Reporter is not required at this time.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: PARK, MIKYONG
FACILITY NUMBER: 434409311
VISIT DATE: 08/03/2021
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LPA Discussed the Individual Infant Sleep Plan with the Licensee.

Licensee also provided a current copy of the Childrens Roster.

A deficiency NOT is being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, An exit interview was conducted, A copy of this report and appeals rights were discussed and left with the Licensee, Mikyong Park, whose signature on this form confirm receipt of these documents.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Sandy Knight
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2021
LIC809 (FAS) - (06/04)
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