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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313626
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:05:40 PM

Document Has Been Signed on 12/16/2024 05:05 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KIM, MONICAFACILITY NUMBER:
304313626
ADMINISTRATOR/
DIRECTOR:		KIM, MONICAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 745-5866
CITY:LA PALMASTATE: CAZIP CODE:
90623
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
12/16/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Licensee, Monica KimTIME VISIT/
INSPECTION COMPLETED:
05:20 PM
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On 12/16/2024, Licensing Program Analyst (LPA), Christine Jung, conducted an onsite inspection for the purpose of an Annual Inspection. At 2:15 PM, LPA was led on a tour by licensee, Monica Kim. The overall census observed was five (5) preschool children, three (3) infant children, and the licensee. During the inspection, it was determined the facility was not operating within its licensed capacity as specified on the license; see LIC 809D for deficiency. Assistant 1 (A1) returned to the facility at approximately 2:50 PM. Facility hours are 8:00 AM – 6:00 PM, Monday through Friday.

The Facility Personnel Report Summary reviewed on this date indicates all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During today’s inspection, LPA and licensee toured the inside areas identified in the facility sketch as accessible to day care children. Off-limits areas are made inaccessible by means of doorknob covers and child gates. The daycare areas consisted of front living room, back living room, bedroom 3, hallway bathroom, and back yard. There were working smoke detector and fire extinguishers in the home that meet statutory requirements. The carbon monoxide detector was not working; see LIC 809D for deficiency.

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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KIM, MONICA
FACILITY NUMBER: 304313626
VISIT DATE: 12/16/2024
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Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. There were no poisons or other items observed which could pose a danger to children. If they were observed, they were locked or inaccessible. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspection. The home had age-appropriate toys for the ages served. LPA verified there is a working telephone service (cellular service), licensee was reminded that childcare phone must remain in the childcare at all times. Licensee stated that they use a section of the backyard for outdoor play which is separated by a baby gate. Licensee stated that there are no bodies of water on the premises.

At 2:20 PM, LPA observed one (1) infant sleeping in bedroom 3. The door to bedroom 3 was closed; see LIC 809D for deficiency. LPA observed loose articles and objects in the play pen which the infants was sleeping in; see LIC 809D for deficiency.

Licensee and A1’s files were reviewed during the facility inspection on this date. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against influenza, pertussis, and measles for licensee and assistant were reviewed. A1 did not have proof of immunization against influenza (or written declaration to decline); see LIC 809D for deficiency.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training and to renew the training every two years. Licensee and assistants are exempt from taking the Mandated Reporter training due to training not being available in Korean. Licensee possesses current EMSA approved Pediatric CPR/First Aid certifications, which expires June 2025.

Five (5) children's records were reviewed. LPA observed two (2) infants from 0-12 months. LPA observed and reviewed LIC 9227 Individual Infant Sleeping Plan and Sleep Log for infants from 0-24 months in children’s files. LPA did not observe LIC 282, LIC 9150, and CDPH 286 in children’s files; see LIC 9102 for Technical Violations.

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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KIM, MONICA
FACILITY NUMBER: 304313626
VISIT DATE: 12/16/2024
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The outdoor activity space was inspected for compliance. The space was enclosed by a fence at least five feet in height. The surface of the outdoor activity space was maintained and free of hazards.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

The licensee understands they must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care for and supervise children while absent. The substitute adult must have the required criminal record clearance, child abuse index clearance, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KIM, MONICA
FACILITY NUMBER: 304313626
VISIT DATE: 12/16/2024
NARRATIVE
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LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Based on LPA’s observations, record reviews, and interview, the following violations were observed and are being cited in accordance with California Code of Regulations, Title 22, Division 12, Chapter 1. See LIC 809D for violations cited: 3 Type A, 2 Type B. See LIC 9102 for 3 Technical Violations.
LPA Jung informed licensee, Monica Kim, that this report dated 12/16/24 documents 3 Type A citations. Type A citations which shall be posted for 30 consecutive days as there are immediate risks to the health, safety, or personal rights of children in care.

Also, LPA Jung informed the licensee, Monica Kim, to provide a copy of this licensing report dated12/16/24 that documents any Type A citations to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at
www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

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SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KIM, MONICA
FACILITY NUMBER: 304313626
VISIT DATE: 12/16/2024
NARRATIVE
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Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee, Monica Kim, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee, Monica Kim.

End of Report.
SUPERVISORS NAME: Martha Malane
LICENSING EVALUATOR NAME: Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2024 05:05 PM - It Cannot Be Edited


Created By: Soo Jin Jung On 12/16/2024 at 04:17 PM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KIM, MONICA
FACILITY NUMBER: 304313626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that, infant play yard used for Child 1 (C1) during nap time was not free from all loose articles and objects, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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Licensee removed all loose articles and objects from the play pen immediately. Licensee stated they will communicate to C1's parents of the regulation stated above and no longer leave loose articles and objects in play pens while being used for nap time.
Type A
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that, licensee did not keep bedroom 3 door open while C1 was sleeping inside, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/16/2024
Plan of Correction
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Licensee opened the door to bedroom 3 and left it open for the remainder of C1's nap time. Licensee stated they will not use a separate bedroom for nap time going forward.
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:Martha Malane
LICENSING EVALUATOR NAME:Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


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Document Has Been Signed on 12/16/2024 05:05 PM - It Cannot Be Edited


Created By: Soo Jin Jung On 12/16/2024 at 04:17 PM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KIM, MONICA
FACILITY NUMBER: 304313626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
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 evidenced by:
Deficient Practice Statement
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Based on observatio and interview, the licensee did not comply with the section cited above in that, licensee was supervising nine (9) children alone upon LPA's arrival, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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Assistant 1 (A1) returned to facility at approximately 2:50 PM. Licensee stated they will submit a plan of action to ensure ratio at all times and submit to LPA via email by due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Martha Malane
LICENSING EVALUATOR NAME:Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


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Document Has Been Signed on 12/16/2024 05:05 PM - It Cannot Be Edited


Created By: Soo Jin Jung On 12/16/2024 at 04:55 PM
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
, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: KIM, MONICA
FACILITY NUMBER: 304313626

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in that, the carbon monoxide detector was not operating properly, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/23/2024
Plan of Correction
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Licensee stated they will ensure the carbon monoxide detector is working properly and send video proof to LPA via email by due date.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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2
3
4
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:Martha Malane
LICENSING EVALUATOR NAME:Soo Jin Jung
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
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