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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093616861
Report Date: 08/13/2019
Date Signed: 08/13/2019 11:41:15 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:MARTINEZ, STEVEN/NICHOLS, KODIEFACILITY NUMBER:
093616861
ADMINISTRATOR:MARTINEZ, S/NICHOLS, K.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 833-5021
CITY:POLLOCK PINESSTATE: CAZIP CODE:
95726
CAPACITY:14CENSUS: 6DATE:
08/13/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Steven Martinez, and Kodie NicholsTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA)Elvira Sierra met with licensees Steven Martinez and Kodie Nichols, for an unannounced Annual/Random inspection. Upon arrival present in the facility was Licensees and husband (co-Licensing)caring for 6 children (1 Infants, 1 Preschool, 4 school age), 2 children are Licensees own children. Facility hours of operation are: M-F from 04:30 AM to 08:30 PM. Capacity and ratio requirements were met on this day. All adults living and working in the home have criminal record clearances on file with Licensing Office. Licensees stated that no new residents moved into the home since licensure.

A health and safety inspection was conducted in all areas accessible to children and the following was observed; Off-limits areas are: Entire upstairs, and Garage. Licensees understand that children may never enter off limit areas. The facility appeared suitable for children and appropriately ventilated. LPA observed the required postings, a working telephone, 2A10BC fire extinguisher and functioning smoke and carbon monoxide detectors. A variety of toys and learning equipment available to the children. Licensees stated there are weapons in the home. Weapons are store according to Tittle 22, ammunition is stored separately and locked. There are no bodies of water on the premises. Medications, toxic and hazardous items are inaccessible to children. Safety latches are in use on some kitchen cabinets, bathroom cabinets and drawers. The applicant understands that she must ensure the safety latches are not broken. The gas stove in the home is appropriately barricaded to prevent access by children. Outdoor play area is fenced for supervision and is free from defects or dangerous conditions. Licensees understands that 100 % supervision is required in unfenced outside areas.
LPA advised Licensees that when temporarily absent from the home, licensees should arrange for a substitute adult to care for and supervise children in her absence. Licensees understand that the Department has inspection authority and may enter and inspect the facility at an anytime, with or without notice. Licensees were advised that all individuals subject to criminal record review shall obtain a criminal record exemption prior to working, residing or volunteering in a licensed home.

Report continued on page 2..
SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MARTINEZ, STEVEN/NICHOLS, KODIE
FACILITY NUMBER: 093616861
VISIT DATE: 08/13/2019
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Children’s files were reviewed. A current roster is being maintained and fire and disaster drills are documented. Preventative health training, current pediatric CPR and first aid certification was verified and expires on 06/2021. Facility provides meals. Mandated Report Training was verified.
This provider is currently not providing IMS services to children in care. 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.

LPA advised the licensees on Safe Sleep Practices and SIDS; Licensees use cribs for sleeping infants and understand infants cannot sleep in car seats, swings or other items not intended for sleeping.

LPA also discussed the Smoking Probation Regulation (AB 1819-Smoking Prohibition), and the Nutritious Beverage Act.Lead Poisoning Facts Information Flyer was provided and Licensees were advised that beginning January 1, 2019 a new law (AB 2370) requires licensed homes and centers to share information on the risks and effects of lead exposure with enrolling and re-enrolling families. Safe Sleep in Child Care, and Quarterly Update Summer 2019 publications were provided.
Licensees were updated on immunization requirements from the Department of Public Health(CDHP) that will become effective July 1, 2019. Additional information and resources can be found on the https://www.shotsforschool.org website.

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.
LPA verified the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the Licensees can request to be added to the distribution list to receive Quarterly Updates. This facility evaluation report was reviewed and discussed with the Licensees. A Notice of Site Visit was provided and should remain posted for 30 days for parental review.

>In the areas that were evaluated, no deficiencies were observed today under Title 22 Division 12 of the Ca. Code of Regulations.

SUPERVISOR'S NAME: Bettina EngelmanTELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Elvira SierraTELEPHONE: (916) 216-8826
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2019
LIC809 (FAS) - (06/04)
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