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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013419328
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:18:57 PM

Document Has Been Signed on 11/09/2023 03:18 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: 5CENSUS: 0DATE:
11/09/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Heesook KimTIME COMPLETED:
03:00 PM
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The conference today was held via Microsoft Teams.

On 11/09/2023 at 2:00PM Licensing Program Manager (LPM), Loretta Dyson and Licensing Program Analyst (LPA), Ashley Curry met with Licensee, Heesook Kim and Licensee’s assistant, Angelina Cho for an announced informal conference.

During this conference we discussed the following deficiencies, some of which were repeat violations:

Health and Safety Code (HSC):
1597.622(a)(1) Staff did not have the required immunization records in file. (Type B Citation)
1597.543 Licensee did not have a working carbon monoxide detector in home. (Type A Citation)

California Code of regulation (CCR):
Type A Citations
102425(j)(5) Infant was sleeping in room alone with the door closed.
102425(A) Infants did not have the LIC 9227 form in file.
102416.5(e) Licensee did not operate as a small FCCH when there is not an assistant present.
102416.5(d)(1) Licensee was operating out of ratio with 5 infants in care at the same time.
Type B Citations
102417(g)(9)(A) Licensee did not conduct fire/disaster drills at least once every six months.
102425(j)(2) Licensee did not provide documented sleep logs for infants.
102418(g) Children did not have the required immunization documentation in file.
102419(d) Two children were missing the LIC 995A form in file.
102417(g)(8) Licensee did not provide a current children’s roster.
102417(m)(3) Licensee did not have signed liability insurance affidavit in children’s files.
SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: KIM, HEESOOK
FACILITY NUMBER: 013419328
VISIT DATE: 11/09/2023
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The facility was cited on 06/15/2023 and 08/31/2023 for the above violations. The licensee assured that she understands the severity of these citations, the importance of not having repeat violations, and staying in compliance with the regulations governing over the facility. After follow up, the licensee submitted proof of corrections for the deficiencies that were cited. Ratio for a small and large license was reviewed with the licensee. LPA will email the licensee the ratio reference chart and LIC 9040 Children Roster form.

The licensee was informed that further noncompliance of the regulations may result in administrative action being taken against the license. The licensee was advised that the facility will have more frequent visits, to help ensure compliance with Title 22 regulations at all times.

Technical Support Program (TSP) was offered to the licensee. The licensee indicated she is interested in TSP. The Department will submit a referral to TSP.

This report shall remain on file for 3 years.

Exit interview conducted, appeal rights were given, and the report was reviewed with the Licensee, Heesook Kim.

SUPERVISORS NAME: Loretta Dyson
LICENSING EVALUATOR NAME: Ashley Curry
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC809 (FAS) - (06/04)
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