<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 334844176
Report Date: 03/22/2022
Date Signed: 03/22/2022 02:23:36 PM

Document Has Been Signed on 03/22/2022 02:23 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:KIM FAMILY CHILD CAREFACILITY NUMBER:
334844176
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 8DATE:
03/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Licensee Holli KimTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/22/2022 at 9:25 AM Licensing Program Analyst (LPA) Susan Brewer, arrived unannounced at the facility to conduct an annual inspection. LPA conducted a COVID19 prescreening and was granted entry by Licensee Holli Kim. LPA toured the facility, inside and out, reviewed records, and observed and/or discussed the following: Present were the Licensee Spouse. A census of 8 children enrolled, 1 infant and 7 toddlers

Normal days and hours of operation are: MONDAY THRU FRIDAY, 7:00AM - 5:30PM

OFF-LIMIT AREAS INCLUDE: Entire 2nd Floor & GARAGE

· The inspection consisted of reviews of the following domain: Physical Plant, Care and Supervision, Records, Facility Administration, Staffing Ratio, Capacity and Personal Rights. The inspection found the facility to be in compliance in these domains, except as noted on the LIC809D, LIC9102TVs & LIC9102TA. Deficiencies cited this visit.


· The facility is operating within the licensed capacity, however the licensee Holli Kim is not operating withing the licensed ratios. At 9:25 AM, LPA took a census of 1 infant and 7 children under the age of 5 years of age.
· The Licensee is present in the home and has ensured that children in care are supervised.
· When temporarily absent from the home, the Licensee shall arrange for a substitute adult to care for and supervise children. The licensee has a Qualified Assistant working in the home.
· A working telephone is present.
· Appropriate fire extinguisher, smoke detector and carbon monoxide detector are present and were tested by the Licensee during this inspection on 03/22/2022.
· All hazardous items are inaccessible, this includes detergents, cleaning compounds, medications and other items which could pose a danger to children
· Storage of poisons is inaccessible to children and locked on 03/22/2022.
· There is a properly barricaded fire place
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KIM FAMILY CHILD CARE
FACILITY NUMBER: 334844176
VISIT DATE: 03/22/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
· Stairs are barricaded on 03/22/2022.
· Home is clean and orderly, with heating and ventilation for safety and comfort
· Safe and appropriate toys and equipment are present for both indoor and outdoor activities.
· Outdoor play areas are fenced and/ or appropriate supervision is present.
· Verification of control of property on file and verified.
· Property owner/landlord notification and consent on file and verified.
· Pediatric CPR and First Aid Card expire on 03/2020. 10:58 AM, CPR/1st Aid training not completed by an EMSA approved vendor and renewal was completed online 02/20/2021.
· Health & Safety Certificate - completed on 10/09/2016
· Mandated reporter: General: NOT ON FILE; AB1207 Child Care Expires: 03/16/2022
· Documentation of fire & earthquake drills to be conducted every six months: Last drill on 0/22/2022 at 9:30 AM, with 7 children, 1 assistant. The drill lasted 10 minutes and went to basketball court across the street.
· There are no bodies of water, at this time. Licensee understands all bodies of water including ponds, above ground pools & spas, in-ground pools & spas, and some fountains must be properly covered or fenced per Title 22 regulations. The Department must be notified before and after installation of the above types of bodies of water. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position.
· Clean, safe and age appropriate toys on 03/22/2022.
· Children’s files are NOT complete, 10:30 am sleep log not on file for Child #1 on Confidential Names List. Records NOT kept for Child #1 LIC9227 Sleep Plan or LIC627, and Child #7 did not have the LIC700 Identification/Emergency form not signed by parents.
· Staff files are NOT complete AB1207 Child Care Expires: 03/16/2022.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KIM FAMILY CHILD CARE
FACILITY NUMBER: 334844176
VISIT DATE: 03/22/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
· No guns or weapons present as stated by the Licensee Holli Kim. Licensee understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 regulations.
Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Plan of Correction discussed with Licensee Holli Kim and proof of correction to submit to the department:

1. Create Sleep Log for Infant Safe Sleep 03/23/2022.

2. Proof of registration/enrollment in Pediatric CPR and First Aid In-Person Training by a approved EMSA Vendor. WWW.EMSA.CA.GOV

3. Proof of completed children's records LIC627 Medical Consent for Child #1 and LIC700 Identification/Emergency Form for Child #7 by 03/23/2022.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee (include name).

Appeal rights discussed and a copy of this report was provided to the licensee on this date.

SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Susan Brewer
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/22/2022 02:23 PM - It Cannot Be Edited


Created By: Susan Brewer On 03/22/2022 at 01:03 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
, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501

FACILITY NAME: KIM FAMILY CHILD CARE
FACILITY NUMBER: 334844176

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(b)(3)


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review of children's files on 03/22/2022, the licensee Hollie Kim, did not comply with the section cited above where a census was conducted and chidlren's records review revealed that 8 out of 8 children in care were under 6 years old and 1 out of 8 children did not have proof of enrollment in Kindergarten placing the facility out of ratio, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2022
Plan of Correction
1
2
3
4
The licensee Holli Kim, agreed notify parents of the conflict for ratio for a child under age 5 and provide the parent until Friday 03/25/2022, to find alternate child care. The licensee agrees to provide proof of at least 1 child's enrollment in Kindergarten. The licensee Holli Kim, agrees to write a statement of understanding of the Title 22 regulations for Capacity and Ratio. Proof of correction will be submitted to Community Care Licensing by 03/25/2022, through fax, mail or e-mail.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
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:Pauline Beschorner
LICENSING EVALUATOR NAME:Susan Brewer
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2022


LIC809 (FAS) - (06/04)
Page: 4 of 4