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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434417288
Report Date: 02/29/2024
Date Signed: 02/29/2024 12:58:37 PM

Document Has Been Signed on 02/29/2024 12:58 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:SONG, JISOOFACILITY NUMBER:
434417288
ADMINISTRATOR:SONG, JISOOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 710-6765
CITY:SAN JOSESTATE: CAZIP CODE:
95117
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
02/29/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:16 AM
MET WITH:Jisoo Song and Sookyoung KimTIME COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Samantha Yip and Marilou Monico conducted an unannounced Case Management-Other inspection. LPAs met with Assistant, Jooyoung (Jasmine) Jeong, and explained the reason the inspection. Licensee Jisoo Song and her spouse arrived shortly after. The purpose of this inspection is to verify that the Licensee is residing in the home. Licensee's relative, Sookyoung Kim arrived around 12:10PM.

During the course of this investigation, LPAs inspected the home. LPA also interviewed Licensee, spouse, and assistant. Licensee and her spouse stated that on the weekends and when the family child care home is closed that she will stay at another home. LPA explained to Licensee and her spouse that per Section 102353(h)(1)-Government Code Section 224 that is states there can only be one residence.

LPAs also observed that A-1 was present at the home and has cleared criminal record and child abuse index, but her fingerprints were not transferred. Licensee was reminded that all adults 18 and over, 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 Child Care Center. 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.

----------------CONTINUES ON 809 DATED 02/29/2024 PAGE 2-----------------
SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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
Document Has Been Signed on 02/29/2024 12:58 PM - It Cannot Be Edited


Created By: Samantha Yip On 02/29/2024 at 11:54 AM
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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SONG, JISOO
FACILITY NUMBER: 434417288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
CCR
102370(d)(2)

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Criminal Record Clearance. All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: Request a transfer of a criminal record clearance...

This requirement is not met as evidenced by:
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By 03/01/2024, Licensee stated that she will transfer A-1's fingerprints to facility roster.
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Based on record reviews, A-1 is not associated to facility roster, which poses an immediate health and safety risk to children in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: SONG, JISOO
FACILITY NUMBER: 434417288
VISIT DATE: 02/29/2024
NARRATIVE
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--------------CONTINUATION OF 809 DATED 02/29/2024 PAGE 1-------------

As a result of this inspection, a Type A and Type B citation were issued. A civil penalty of $200 was issued for caregiver background check and $250 for repeat violation. Exit interview was conducted and report was reviewed with Licensee Jisoo Song and her relative Sookyoung Kim, who helped translate. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Licensee, Jisoo Song, that this report dated 02/29/2024 document(s) one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Licensee to provide a copy of this licensing report dated 02/29/2024 that documents any Type A citation(s) 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.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/29/2024 12:58 PM - It Cannot Be Edited


Created By: Samantha Yip On 02/29/2024 at 12:29 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: SONG, JISOO
FACILITY NUMBER: 434417288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2024
Section Cited
HSC
1596.78(a)

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“Family day care home” "Family day care home" means a home that regularly provides care, protection, and supervision for 14 or fewer children, in the provider's own home, for periods of less than 24 hours per day, while the parents or guardians are away, and is either a large family day care home or a small family day care home.
This requirement is not met as evidenced by:
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By POC 03/07/2024, Licensee will submit proof that this home is her only residence per Section 102352(h)(1).
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Based on interview, Licensee stated that she will stay at another home on the weekends and when the FCCH is closed. This poses a potential health and safety risk to children in care.
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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:Joel Segura
LICENSING EVALUATOR NAME:Samantha Yip
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
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