Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300615740
Report Date: 04/14/2016
Date Signed 04/14/2016 03:51:24 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:ANNA JAE KIMFACILITY NUMBER:
300615740
ADMINISTRATOR:KIM, JAE SOONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 636-3314
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:14CENSUS: 4DATE:
04/14/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Anna Jae Kim - LicenseeTIME COMPLETED:
04:00 PM
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LPA Jane Cong-Huyen met with licensee, Anna Kim, for a annual random visit (2). LPA toured areas of the home inside and outside and areas accessible to the children. The home is a one level home with 4 bedrooms and 2 bathrooms. Licensee stated that OFF LIMITS areas include: all bedrooms, main family room, both side yards area with sheds and right end back yard area that is gated and garage. Licensee acknowledged that children may never enter these off-limit areas. The census includes 4 daycare children with ages ranging from 3.5 to 5 years old. (all preschool children) Licensee stated there are no new residents in the home since licensed. Licensee stated that she is not registered with any Foster Care agency. A review of family member/staff records on this date indicates that all family members and/or other individuals who required caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was able to show proof of CPR (exp:11/2016) and First Aid (exp: 11/2016) that is EMSA certified for herself and for her adult daughter, Jenny. LPA observed posted Parent's Rights and current disaster plan. LPA also reviewed children's records and children's roster. There is no fireplace in the home. Licensee stated there are no weapons in the home. LPA observed all sharp utensils, hazardous chemicals and medication are stored up high or in latched/locked cabinet which is inaccessible to children in care. Fire extinguisher, carbon monoxide and smoke detectors meet regulations. LPA observed fire drills log. There is no bodies of water on the premises. The home has no pets. LPA discussed about Incidental Medical Services (IMS) to the licensee and she stated that she is not providing medication to children. She said if she changes her mind she will contact licensing office.

No deficiency cited during today's visit.
Exit interview was conducted. The 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. LPA informed the director of how to access regulations and forms from CCLD websites: www.ccld.ca.gov or Myccl.ca.gov. This report is to be on file and accessible for public review at the facility for at least 3 years.
SUPERVISOR'S NAME: Dana WilliamsonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Jane Cong-HuyenTELEPHONE: (714) 703-2818
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2016
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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