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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314303
Report Date: 12/10/2024
Date Signed: 12/10/2024 03:05:20 PM

Document Has Been Signed on 12/10/2024 03:05 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:SHIN, STELLAFACILITY NUMBER:
304314303
ADMINISTRATOR/
DIRECTOR:		SHIN, STELLAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(626) 727-0178
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
12/10/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Assistant Misun Kim and Licensee, Stella ShinTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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On 12/10/24 at 12:15pm, An Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Sarah Garcia. LPA met with assistant, Misun Kim and census was taken. There were 12 children with 1 staff in day care area. The facility was operating out of ratio and out of compliance of licensed capacity as specified on license. At 12:30pm, licensee, Stella Shin arrived at the facility. LPA and licensee conducted a walk through of the facility. At 1:00pm, an additional staff member arrived at the facility.
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. Facility Day care hours are 8am-6pm, Monday through Friday.

During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of safety door knobs and safety gates. The child care area consist of the living room and the bedroom which is accessed through the front door. The children's bathroom is located in the bedroom. Licensee stated the children's primary area is the living room. There are working carbon monoxide, smoke detector, and fire extinguishers 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 no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. There is a fireplace in the living room barricaded and inaccessible to children in care. The home has age appropriate toys for the ages served. LPA verified there is a working telephone service. LPA inspected the outdoor area. LPA observed safe and age appropriate toys and materials. 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.


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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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: SHIN, STELLA
FACILITY NUMBER: 304314303
VISIT DATE: 12/10/2024
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The licensee does not have a current roster of children in care. LPA provided licensee a copy of LIC 9040. (12) children's records for children present during LPA’s inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance.

The licensee and assistant's Pediatric CPR/First Aid certification expires 11/2025. 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. Proof of immunization against pertussis, measles for licensee and assistants 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.



Incidental Medical Services (IMS) policy was discussed. 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

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.

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 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. Continued on Page 3

SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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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: SHIN, STELLA
FACILITY NUMBER: 304314303
VISIT DATE: 12/10/2024
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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 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.



The licensee was informed of the Important Updates available at www.ccld.ca.gov and may request to be added to an email list to receive Community Care Licensing Important Notifications from the above website and selecting Receive Important Updates link

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
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.asp
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials
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

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SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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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: SHIN, STELLA
FACILITY NUMBER: 304314303
VISIT DATE: 12/10/2024
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· 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.
The facility was not in compliance doing today's visit. The following violations of the California Code of Regulations, Title 22; Division 12, were observed and cited today: Staffing Ratio and Capacity 102416.5 (e) (see LIC 809D). LPA provided a copy of regulation Section 102416.5 to licensee for reference.

Due to the Type A violations cited today, the licensee shall post, and provide copies, of the report to parents/guardians of the children in care at the facility by the next business day, and shall provide to the parents/guardians of children newly enrolled at the facility during the next 12 months. The licensee is to keep Acknowledgement Receipt (LIC 9224) signed by parents in each child’s file. In addition, the licensee shall immediately post upon receipt the Proof of Correction for 30 consecutive days.

During the exit interview, the LICENSEE Stella Shin 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, Stella Shin.

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 [email protected]. 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.

End of Report.
SUPERVISORS NAME: Patricia Magana
LICENSING EVALUATOR NAME: Sarah Garcia
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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Document Has Been Signed on 12/10/2024 03:05 PM - It Cannot Be Edited


Created By: Sarah Garcia On 12/10/2024 at 01:57 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: SHIN, STELLA
FACILITY NUMBER: 304314303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2024

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 observation, the licensee did not comply with the section cited above in LPA observed 12 children with 1 staff which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/11/2024
Plan of Correction
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Licensee agreed to watch CDSS video and copy of regulation 102416.6 on ratios and submit declaration stating what they have learned. https://ccld.childcarevideos.org/
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:Patricia Magana
LICENSING EVALUATOR NAME:Sarah Garcia
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2024


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