093616861-5-9-2023-03-CC-SMAX-CRNQ8Y-20230509115731

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 093616861
Report Date: 05/09/2023
Date Signed: 05/09/2023 11:57:45 AM

Document Has Been Signed on 05/09/2023 11:57 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	MARTINEZ, STEVEN/NICHOLS, KODIE		FACILITY NUMBER:	093616861
ADMINISTRATOR:	MARTINEZ, S/NICHOLS, K.		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 833-5021
CITY:	POLLOCK PINES	STATE: CA	ZIP CODE:	95726
CAPACITY:	14	CENSUS: 7	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Steven Martinez/Kodie Nichols		TIME COMPLETED:	12:15 PM

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On May 9th, 2023, Licensing Program Analysts (LPAs) Soleil Marx met with Licensee, Steven Martinez/Kodie Nichols, for an unannounced annual / one year inspection. During the inspection there was a census of 7 children in care being supervised by the two licensee's. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are 7:00 AM-4:30 PM.

A health and safety inspection was conducted in the areas accessible to children. The home is a two-story home and the on-limits areas include the entire downstairs area and the fenced play yard. The off-limits areas include the backyard area other than the fenced off play yard, the entire upstairs, garage. Licensee understands that children may never enter these off-limits areas. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPA observed all required postings. LPA observed home was safe, orderly, and free of hazards. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. The fireplace and stairs in the home are appropriately barricaded. Firearms are properly stored to meet regulation, secured in a locked safe and ammunition is in a separate locked safe. There are no bodies on the premises.

LPA observed a children's roster and fire drill log, the last fire drill was conducted 04/04/2023. Licensee has CPR/First aid, which expires 03/2023 and is enrolled to renew. Licensee has current Mandated Reporter Training, which expires 04/2024. Licensee understands both CPR and mandated reporter training's’ must be completed every two years.

LPA reviewed records of children’s files, all which contained the required documentation. (1/2)

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: MARTINEZ, STEVEN/NICHOLS, KODIE	FACILITY NUMBER: 093616861
	VISIT DATE: 05/09/2023

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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.

Licensee is aware of and/or practicing safe sleep regulations.

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.

No deficiencies were cited during today’s inspection.

Exit interview conducted and report was reviewed with the Licensee. A notice of site visit was provided and must remain posted for 30 days (2/2)

SUPERVISOR'S NAME: Natalie Dunaway	TELEPHONE: (916) 584-3508
LICENSING EVALUATOR NAME: Soleil Marx	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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