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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419328
Report Date: 08/31/2023
Date Signed: 08/31/2023 11:33:59 AM

Document Has Been Signed on 08/31/2023 11:33 AM - 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: 10DATE:
08/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Heesook KimTIME COMPLETED:
02:30 PM
NARRATIVE
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On 08/31/2023 at 11:45AM Licensing Program Analyst (LPA), A. Curry conducted an announced case management inspection to follow up on deficiencies that were cited at the facility. LPA met with the licensee Heesook Kim, to explain the purpose of today's visit. Upon arrival, licensee was alone with 10 children in care, consisting of 2 infants and 8 preschoolers (See 809D). The licensee's husband arrived shortly after. LPA observed C1 (infant) sleeping on C1's stomach with a bib around C1's neck and in a room with the door closed (See 809D). The infant did not have the LIC 9227 form in file (See 809D). LIC 9227 form was provided during today's visit. During the visit the LPA was informed the licensee still does not have required immunization records for assistants (See 809). A Civil penalties will assessed today. Civil penalties will continue to accrue $100 per day until deficiencies are corrected.


Exit interview conducted, appeal rights were given, and report was reviewed with the licensee Heesook Kim.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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 4
Document Has Been Signed on 08/31/2023 11:33 AM - It Cannot Be Edited


Created By: Ashley Curry On 08/31/2023 at 10:47 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: KIM, HEESOOK
FACILITY NUMBER: 013419328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/08/2023
Section Cited
HSC
1597.622(a)(1)

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§1597.622 Employees or volunteers at family day care home..(a) (1)...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...
This requirement is not met as evidence by:
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By 09/08/2023 the licensee will submit proof of immunity for measles and pertussis for all assistants.
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Based on interview and record review, the facility did not comply with the section cited above by ensuring all assistants have the required immunization records in file.
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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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/31/2023 11:33 AM - It Cannot Be Edited


Created By: Ashley Curry On 08/31/2023 at 10:57 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: KIM, HEESOOK
FACILITY NUMBER: 013419328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
102425(j)(5)

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102425INFANT SAFE SLEEP(j)The provider shall supervise infants while they are sleeping and adhere to the following requirements: (5)If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.
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Licensee opened the door during the visit and placed infant on stomach.

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This requirement was not met as evidence by:
LPA observed an infant sleeping on stomach in a room with the door closed.
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Type A
09/01/2023
Section Cited
CCR102425(c)

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102425 INFANT SAFE SLEEP(c) An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 month of age the provider has in care and maintained at the facility in the infant’s file.
This requirement is not as evidence by:
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By 09/01/2023 submit LIC 9227 for infant. LIC 9227 form was provided during visit.
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Based on observation and record review, the facility did not comply with the section above by ensuring all infants up to 12 months of age has the LIC 9227 form in file.
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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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/31/2023 11:33 AM - It Cannot Be Edited


Created By: Ashley Curry On 08/31/2023 at 11:11 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: KIM, HEESOOK
FACILITY NUMBER: 013419328

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2023
Section Cited
CCR
102416.5(e)

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102416.5 Staffing Ratio and Capacity (e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).
This requirement is not met as evidence by:
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By 09/01/2023 the licensee will submit in writing how she will comply with the regulation.
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Based on observation the licensee did not comply with the section above by operating as a small when no assistant is present. Upon arrival LPA observed the licensee alone with 10 children.
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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:Loretta Dyson
LICENSING EVALUATOR NAME:Ashley Curry
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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