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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419328
Report Date: 07/25/2023
Date Signed: 07/25/2023 12:37:26 PM

Document Has Been Signed on 07/25/2023 12:37 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:KIM, HEESOOKFACILITY NUMBER:
013419328
ADMINISTRATOR:KIM, HEESOOKFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 533-3922
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
07/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Heesook KimTIME COMPLETED:
01:30 PM
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On 07/25/2023 at 12:00PM Licensing Program Analyst (LPA), A. Curry conducted an unannounced case management inspection to follow up on deficiencies that were previously cited. Licensee did not clear multiple citations. Civil penalties will be assessed. Civil penalties will continue to accrue $100 per day until deficiencies are cleared.

Exit interview conducted, appeal rights were given, and report reviewed with the licensee Heesook Kim.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2023
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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