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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313783
Report Date: 07/09/2021
Date Signed: 07/09/2021 03:53:18 PM

Document Has Been Signed on 07/09/2021 03:53 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:CHANG, YOURIMFACILITY NUMBER:
304313783
ADMINISTRATOR:CHANG, YOURIMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(714) 337-0075
CITY:IRVINESTATE: CAZIP CODE:
92620
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
07/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Yourim Jean ChangTIME COMPLETED:
04:20 PM
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An Annual inspection was conducted at the facility by Licensing Program Analyst (LPA) Valencia. Licensee was operating within the licensed capacity as specified on license. Due to COVID 19 guidelines, LPA observed staff and children wearing face mask, social distancing and following CDC and Dept of Public Health Guidelines. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults residing in the facility. Facility Day care hours are 2pm-6pm, Monday through Friday. In the summer, 9am to 5pm, mon-fri.

During today’s inspection, LPA and licensee toured the inside and outside areas of the facility. Off limits areas are made inaccessible by means of baby gate. The childcare area is the living room and dining room area. Licensee stated the children's primary area is the childcare room. There is at least one working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. Licensee stated there are not firearms and/or other dangerous weapons in the facility, and none were observed during today's inspections. The home has age appropriate toys for the ages served. During today’s inspection LPA verified there is a working telephone service (cellular service). Licensee stated they use the backyard as an outdoor play area. The backyard play area was inspected and is free from hazards. There were no poisons or other items observed which could pose a danger to children or if they were observed, they were locked or inaccessible. There are no bodies of water on the premises. The licensee has a current roster of children in care. Children’s records for children present during LPA’s inspection were reviewed. The licensee’s Pediatric CPR/First Aid certification is current and expires 5/2022. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. (continued on LIC809C)
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Valencia
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2021
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 3
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: CHANG, YOURIM
FACILITY NUMBER: 304313783
VISIT DATE: 07/09/2021
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Proof of immunization against pertussis, measles for licensee and any adult working with children were reviewed and within compliance. 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.
This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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.htmThe 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 and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, 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.ccld.ca.gov 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. Licensee does/does not have lead training Certificate. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee. The following electronic links were also provided:


English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

(continued on LIC809C)
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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: CHANG, YOURIM
FACILITY NUMBER: 304313783
VISIT DATE: 07/09/2021
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LPA reviewed with licensee the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used if they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not be too hot or too cold.

In the areas that were evaluated, NO deficiencies were observed of the California Code of Regulations, Title 22, Division 12 during today’s inspection.

An exit interview was conducted with licensee. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door/facility entrance.
SUPERVISORS NAME: Judy Hanson
LICENSING EVALUATOR NAME: Dean Valencia
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC809 (FAS) - (06/04)
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