Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304312281
Report Date: 04/07/2017
Date Signed 04/07/2017 01:30:11 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, EUN HYANGFACILITY NUMBER:
304312281
ADMINISTRATOR:KIM, EUN HYANGFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 943-6657
CITY:LA PALMASTATE: CAZIP CODE:
90623
CAPACITY:14CENSUS: 10DATE:
04/07/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Eun Hyang KimTIME COMPLETED:
01:45 PM
NARRATIVE
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(1) Licensing Program Analyst (LPA), Jacqueline Moore, met with licensee, Eun Hyang Kim who greeted and allowed LPA entrance into the facility. Licensee was supervising 7 daycare children in the front day care room. Also present and assisting with the day-care children was assistant, Jakyung Chun who was supervising 3 day care children in the second day care room. Census included 4 infants and 6 preschoolers.
A review of criminal record clearances indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are 2 adults 3 minor children living in the facility.
Licensee stated that OFF LIMITS areas include: the entire second floor and garage. Licensee acknowledged that children may never enter these off-limit areas. LPA observed there are three gates which prevent the children from having access to the kitchen area. Per licensee, the children are allowed to go through the kitchen to pass through to go into the backyard.

The daycare area was inspected for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medication, and hazardous items that can pose a danger to children. Per licensee there are no weapons or firearms or bodies of water in the facility. Fireplace was barricaded and stairs were gated during inspection. There are age appropriate toys and equipment for ages served.

The children are using the enclosed back yard area of the home as outside play area. The required fire extinguisher (2A10BC), smoke detector, and carbon monoxide detector were in operable condition. Licensee had current CPR/First Aid cards which expire (11/9/18) and EMSA certified. Emergency information was reviewed for children in care. Copy of current children's roster was given to LPA.
Staff #1 and Staff #2 did not have the required immunization's for Pertussis, Measles, and Influenza on file during today's inspection.
SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KIM, EUN HYANG
FACILITY NUMBER: 304312281
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2017
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2017
Section Cited
H&S 1597.622
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Employee and Volunteer Immunization: (a) (1) Commencing September 1, 2016, 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. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year
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Licensee plans to resolve the issue by having the Measles, Pertussis, and Influenza immunization's completed and will send to the licensing office by due date of 05/08/17.
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Staff#1 and Staff #2 did not have Measles, Pertussis, and Influenza immunization's on file for review during today's inspection
This may pose a potential health and safety risk to 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: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2017
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KIM, EUN HYANG
FACILITY NUMBER: 304312281
VISIT DATE: 04/07/2017
NARRATIVE
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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 following were discussed: Individuals who are 18 years of age or older living in the home must be fingerprint cleared prior to presence in the facility. No smoking, disaster drills, posting requirements, children records, mandated child abuse and injury/death reporting. LPA reviewed Unusual Incident Report form (advised to contact Licensing Officer of the Day within 24 hours and complete the Unusual Incident Report (LIC 624) within 7 days), and criminal records clearances/exemption transfer requests (contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182) and (LIC 508) with copy of ID to fax# (714)703-2831 prior to hiring staff), SIDS and Never Shake a Baby(Copy given), Quarterly updates, SB 792(copy was given) CA child passenger safety law (copy was given), Complaint and information Bureau ( copy was given)The Chaptered Legislation for AB 2084 (Nutritious Beverages). Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. A copy of the 2016 “A Child Care Providers Guild to Safe Sleep” was provided to the facility representative. English:https//www.cdph.ca.gov/programs/SIDS/Doucments/SIDSchildcaresafesleep.pdf.

LPA reviewed areas accessible to day care children, which included, front day care room, second back day care room, downstairs bathroom, and back yard. In the areas evaluated, deficiency was observed, discussed and cited today per CA Code of Regulations, Title 22, and Division 12.

An exit interview was conducted. Report was reviewed and discussed. The licensee was provided a copy of their appeal rights (LIC 9058 12/15) and their signature on this form acknowledges receipt of these rights. 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 licensee of how to access regulations and forms from CCLD websites. This report is to be on file and accessible for public review at the facility for at least 3 years.

SUPERVISOR'S NAME: Marian WallmeierTELEPHONE: (714) 703-2800
LICENSING EVALUATOR NAME: Jacqueline MooreTELEPHONE: (714) 703-2821
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2017
LIC809 (FAS) - (06/04)
Page: 2 of 3