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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093610094
Report Date: 08/23/2023
Date Signed: 08/23/2023 12:04:33 PM


Document Has Been Signed on 08/23/2023 12:04 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:KOFF, KATHRYNFACILITY NUMBER:
093610094
ADMINISTRATOR:KOFF, KATHRYNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 941-1199
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY:14CENSUS: 8DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Kathryn KoffTIME COMPLETED:
12:20 PM
NARRATIVE
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On August 23rd, 2023, Licensing Program Analyst (LPA) Soleil Marx met with Licensee, Kathryn Koff, for an unannounced annual / one year inspection. During the inspection there was a census of 8 children in care being supervised by the licensee and assistant. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are Monday through Friday 08:00 AM to 05:00 PM.

A health and safety inspection was conducted in the areas accessible to children. The off-limits areas include: entire upstairs, living room with fireplace, kitchen, laundry room, garage, 2 decks (off living room and upstairs, both off limit areas). The on-limit areas used are the day-care room, bathroom, deck off the day-care room (with 100% supervision), and backyard. Licensee understands that children may never enter off-limits areas.

LPA observed a working telephone, functioning smoke detector, and a 2A10BC fire extinguisher within the home. Licensee stated she does not have a carbon monoxide detector within the home. LPA observed home was safe, orderly, and free of hazards. LPA observed a variety of age-appropriate toys within the home. LPA observed fireplace and stairs within the home are properly barricaded to meet regulations. Licensee stated there are no bodies of water on the premises. LPA observed firearms within the home are properly secured and locked to meet regulation. Licensee understands that if there are any poisons in the home, all poisons must be locked with a key lock or combination lock.

LPA observed all required postings, a children's roster, and fire drill log. LPA reviewed records of children’s files and staff files, all which contained the required documentation. Licensee and assistant have current EMSA approved pediatric CPR/First Aid training, which expires 03/2025. Licensee and assistant do not have current Mandated Reporter Training. Licensee understands both CPR and mandated reporter training's’ must be completed every two years.

SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil MarxTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KOFF, KATHRYN
FACILITY NUMBER: 093610094
VISIT DATE: 08/23/2023
NARRATIVE
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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.

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-andresources/safe-sleep as an additional resource. LPA also informed licensee [or facility representative] 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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.

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 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/inspection-process.

Title 22 deficiencies are being cited on 809-D

During the exit interview, the licensee, Kathryn Koff, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Exit interview conducted and report was reviewed with the licensee, Kathryn Koff. A notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil MarxTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/23/2023 12:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: KOFF, KATHRYN
FACILITY NUMBER: 093610094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above by not having a carbon monoxide detector within the home, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/06/2023
Plan of Correction
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Licensee will get a functional carbon monoxide detector to keep within the home and send proof the LPA Marx by POC due date.
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not having current mandated reporter training for Licensee or assistant, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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Licensee and assistant will complete Mandated Reporter Training and send completion certificates to LPA Marx by POC due date.
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: Natalie DunawayTELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil MarxTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3