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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010033
Report Date: 05/27/2022
Date Signed: 05/27/2022 10:12:20 AM


Document Has Been Signed on 05/27/2022 10:12 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BOHAN, NAHANI FCCHFACILITY NUMBER:
173010033
ADMINISTRATOR:BOHAN,NAHANIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 287-0551
CITY:KELSEYVILLESTATE: CAZIP CODE:
95451
CAPACITY:14CENSUS: 0DATE:
05/27/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nahani BohanTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Sebastian Phouthavong made a Case Management Visit on 08/31/21, returning the facility to active status. The Department received form LIC9211 Request for Inactive Child Care License Status beginning 08/26/21 through 01/02/2022. On 05/16/2022, LPA Sebastian Phouthavong received an email from Licensee, Nahani Bohan requesting to end the inactive status and return to active status before 06/01/2022. During today’s visit, LPA met with Licensee, Nahani Bohan.

A review of staff records indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. The Licensee was reminded that all adults 18 and over, 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 Child Care Center. 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.

During today’s visit the facility was toured and the facility sketch verified. Operating hours are 8:00am – 5:00pm Monday – Friday. At least one staff member will be present during the inspection. The licensee’s pediatric CPR and First Aid certifications were reviewed and expire in 2023. LPA verified that the facility has a current fire extinguisher; rated at least 2A10BC, functioning smoke alarm and carbon monoxide detector. LPA Sebastian Phouthavong reviewed form LIC311A Records to be maintained at the facility with the Licensee. There is a pool located at the premise and LPA Sebastian Phouthavong reviewed the fencing requirements when a body of water is present.

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.

Exit interview conducted and report was reviewed with Licensee, Nahani Bohan.

License is ready to return to active status and will be active starting, 5/27/2022

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Sebastian PhouthavongTELEPHONE: 707-588-5056
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
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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