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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417288
Report Date: 11/14/2022
Date Signed: 11/14/2022 12:07:26 PM

Document Has Been Signed on 11/14/2022 12:07 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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SONG, JISOOFACILITY NUMBER:
434417288
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
11/14/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Jisoo SongTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Pete Hernandez conducted an announced Case Management Visit - Other. Licensee has applied for a relocation and increased capacity to a large family home. LPA met with Licensee, Jisoo Song and explained the purpose of today's inspection. Present in the home was the Licensee's Uncle Kihan Park and Aunt Sookyoung Kim whom assisted with translation. Licensee lives in the home with her husband, whom was not present at the time, and two minor children. There were 2 children present at the time of the visit; both were the licensee's children. Licensee has day-care insurance for the home. The hours of operation are Monday through Friday 9:00AM to 6:00PM.

LPA toured the indoor and outdoor areas of the home during today's inspection: In Use
Areas: Family room, living room, dining room, hall and bathroom in hallway and backyard. Off Limit Areas: Master bedroom and master bathroom, All 3 other bedrooms, kitchen, and garage and storage shed in back yard. The the side of the house in the back yard facing north (on the left) is barracked and off limits.
Licensee understands that fire drills are to be conducted are every 6 months. Licensee will maintain a current children's' roster. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is orderly, and safe for the day care children.
LPA observed a fully charged 3A40BC fire extinguisher in the kitchen. There are working smoke & carbon monoxide detectors. LPA did not observe any bodies of water on the immediate property. This is inaccessible to the children in care. The Licensee understands that all pools, spas, hot tubs, fish ponds, or similar bodies of water shall be covered or fenced as specified in title 22 regulations to be inaccessible to children. Licensee states that there are no weapons or firearms in the home. All detergents, cleaning compounds, other similar items and poisons are out of reach, or locked up, and are inaccessible to children.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 11/14/2022:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2022
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SONG, JISOO
FACILITY NUMBER: 434417288
VISIT DATE: 11/14/2022
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Incidental Medical Services (IMS) policy was discussed. When any IMS is provided, an updated Plan of Operation that includes 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

A review of staff records today indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12- month period

Supervision of children was discussed with the Licensee. Licensee understands that she must be present in the home at least 80 percent of the hours the day care is in operation and ensure that the children are supervised at all times. The Licensee understands her capacity options. The Licensee states that she does transport children and understands that children cannot be left in parked vehicles unattended at any time. Licensee understands that children's personal rights should not be violated; including no corporal punishment. Isolation of sick child, requirements for reporting suspected child abuse, unusual incidents/injuries, heat-related illnesses, and requirements for assistant/substitute were also discussed.
LPA informed Applicant that Licensing forms and Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov

LPA reviewed the pre-licensing package to assist the licensee because she has not been operation for several month.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #3 - REPORT DATED 11/14/2022:
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
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
SAN JOSE-DAY CARE, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SONG, JISOO
FACILITY NUMBER: 434417288
VISIT DATE: 11/14/2022
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Licensee has current Mandated Reporter Certificate and will expire on 4/14/2023. LPA discussed Senate Bill 792, Assembly Bill (AB) 1207 (Mandated Child Abuse Reporting Training) which is required training that began on January 1, 2018 and requires renewal every two years, AB 633 was discussed with applicant Licensing forms, Title 22 regulations, can be obtained through the internet at www.ccld.ca.gov. Mandated Reported Training can be accessed atwww.mandatedreporterca.com.
Licensee has a current CPR and First Aid card that expires 5/8/2023.

Licensee understands that if the license is approved she must reside in the home licensed and all helpers and adult residents must be associated to the license.

Website for resource information: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

LPA also provided the e-mail address for the advocates in order to be added to the quarterly newsletter mailing list, [email protected]

Upon the issuance of Type A citations, a copy of the Facility Evaluation Report LIC809 has to be posted on the wall and a copy to be given to all parents of currently and newly enrolled children for next 12 months. In addition, copy of LIC9224 Statement Acknowledging Receipt of Licensing Reports need to be signed and kept in child files.

A deficiency is NOT being cited based on the LPA observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with the Applicant. A copy of this report was discussed and left with the Licensee, Jisoo Song , whose signature on this form confirm receipt of these documents.

Licensee understands that this request for a large family child care home requires management review and approval prior to issuance of a license

A NOTICE OF SITE VISIT WAS ISSUED, AND TO BE POSTED NEAR THE ENTRANCE TO THE FACILITY, AND MUST REMAIN POSTED FOR 30 DAYS.
SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Pietro Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
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