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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093616861
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:36:11 AM


Document Has Been Signed on 06/02/2022 10:36 AM - 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, 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:
(916) 833-5021
CITY:POLLOCK PINESSTATE: CAZIP CODE:
95726
CAPACITY:14CENSUS: 10DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Steven Martinez/Kodie NicholsTIME COMPLETED:
10:45 AM
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On 06/02/2022 at approximately 9:20am Licensing Program Analyst (LPA) Arianna Manabat met with licensee Steven Martinez/Kodie Nichols for an unannounced annual / one year inspection. During the inspection there were ten day care children. All individuals subject to criminal background review have obtained a criminal record clearance.

The home is a two-story home and the on-limits areas include the entire downstairs area and the fenced play yard with the two climbing structures. The off-limits areas include the backyard area other than the fenced off play yard and the entire upstairs area. There are no bodies of water observed. The licensee has three separate locked safes for weapons in the home and LPA observed that the firearms are properly stored.

A health and safety inspection was conducted in the areas accessible to children. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPA observed all the required postings. LPA observed that any poisons within the home are locked under the sink with a key lock or combination lock. LPA observed a fireplace within the facility that was barricaded.

Licensee has all immunization records current. Children's roster and a fire drill log were observed, the last fire drill was conducted on April 4th, 2022. Licensee's CPR/First aid card had an expiration date of March 2023. Mandated Reporter Training for licensee had an expiration date of April 2024. Licensee understands training must be complete every two years. LPA observed complete children's files.

Report continues on 809C................

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) -26-1414
LICENSING EVALUATOR NAME: Arianna ManabatTELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MARTINEZ, STEVEN/NICHOLS, KODIE
FACILITY NUMBER: 093616861
VISIT DATE: 06/02/2022
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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 reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/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-and-resources/safe-sleep as an additional resource. LPA also informed Licensee 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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. No deficiencies were cited during today’s inspection. Exit interview conducted and report was reviewed with the Licensee Steven Martinez/Kodie Nichols.

SUPERVISOR'S NAME: Maria MayorgaTELEPHONE: (916) -26-1414
LICENSING EVALUATOR NAME: Arianna ManabatTELEPHONE: (279) 200-2886
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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