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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313899
Report Date: 06/23/2021
Date Signed: 06/23/2021 01:50:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:KAKI, SUNDA BENITOFACILITY NUMBER:
304313899
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
06/23/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Sunda Kaki, ApplicantTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA), Stacy Torrence conducted an announced pre-licensing inspection of the facility on today's date. The LPA toured the facility with the applicant, Sunda Benito Kaki. A review of criminal clearance records on this date indicates adults who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are two adult residents and four minor children living in the home; no assistants. Applicant stated she is not currently registered with any Foster Care agency or holds a foster parent license. Applicant was reminded to notify the licensing office, if this changes.

The facility is a single-story home with four bedrooms, two bathrooms, living room, dining room, kitchen, attached garage, front yard (not fenced) and backyard that is fenced. The applicant has designated one bedroom, one bathroom, and the covered patio as part of her day-care. Applicant has designated three bedrooms, one bathroom, living room, dining room, kitchen, attached garage, front yard, and backyard as off limit areas. Applicant has placed a child proof gate at the entrance of the bedroom, which is the daycare room, ensuring the off-limit areas are inaccessible to children, during operation hours. The applicant acknowledged the children may never enter the off-limit areas. Control of property was verified by LPA during today’s inspection. The applicant has a cell phone that is used for childcare. The applicant was informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. Applicant was informed and understands the home is to be free from smoking during hours of operation.

The facility has a fireplace, located in the living room, which is the off-limit area and is barricaded with a door that locks automatically when closed. Cleaning solutions/chemicals, utensils, and sharp knives located in the kitchen, which is designated as the off-limit area. Poisons/Hazardous items are not stored on site, and none were observed. There is a body of water pool located in the backyard which does not meets Title 22 regulations 102417(g)(5) the self-latching fence gate leading to the pool was not working properly.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KAKI, SUNDA BENITO
FACILITY NUMBER: 304313899
VISIT DATE: 06/23/2021
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 Per applicant’s husband he will bolt the metal plate on to the fence door, ensuring the fence cannot not open, making the pool inaccessible to the children in care. The toys are age appropriate and in good condition for the potential ages served. Baby walkers, bouncers, jumpers, and similar items will not be used for children in care. The applicant stated there are not weapons or firearms on the premises. When firearms are present, they must be locked and stored separately from the ammunition. During today's inspection, the smoke detector and carbon monoxide were operable, and the fire extinguisher was charged.
EMSA approved Pediatric CPR & Pediatric First Aid are current for the applicant and expires on 01/2023. Applicant completed the 8-hour Preventative Health Practices, Nutrition Course on 07/16/2016 and Lead Poisoning Preventive Courses with A-B-CPR and First Aid on 05/27/2021.

This facility plans to provide Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

The following was discussed with applicant: Individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to being present in the facility. LPA provide applicant with website for Live-Scan locations oag.ca.gov/fingerprints/locations for all adult complete LIC 9163. If adult is fingerprinted cleared and associated to another facility, licensee must submit a Criminal Record Transfer Request (LIC 9182) or Exemption Transfer Request form (LIC 9188). Contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182 or LIC 9188) with copy of a valid identification issued by State or Federal Government and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult. Failure to complete the clearance process or license association for any adult resident or assistant will result in a civil penalty assessment against the license.

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KAKI, SUNDA BENITO
FACILITY NUMBER: 304313899
VISIT DATE: 06/23/2021
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LPA reviewed Unusual Incident Report (UIR) form (LIC 624B)-advised to contact Licensing Officer of the Day within 24 hours and complete the UIR within seven days by faxing LIC624B to (714)703-2831. LPA advised applicant to report to licensing any unusual incident or child absence that threatens the physical or emotional health or safety of any child or any changes to hours and days of operation and also for any changes to facility, including on/off limit areas and change in phone number.

LPA reviewed with applicant requirements of Disaster Preparedness drills (documented every 6 months). The LPA advised of Affidavit Regarding Liability Insurance (LIC 282) if did not purchase liability insurance and to maintain the form in the children's files, and Car Safety Seat pamphlet were discussed and provided to the applicant. Posting requirements which include but not limited to Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9141), Parents Rights (PUB 394), Notice of Site Visit (LIC 9213), and License (LIC 203). LPA reviewed with applicant the need to maintain records including but not limited to Children records and Staff/Adults records, (LIC 311D).

Applicant was informed of Mandated Reporter Training for self and all assistants. Department website http:/www.ccld.ca.gov was given to download forms, Title 22 regulations, Providers Information Notices, and online trainings. The applicant was also informed to visit the website for Quarterly Updates. The applicant was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov.

LPA reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.
A copy of “A Child Care Providers Guild to Safe Sleep” was provided to applicant:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
Spanish: https//www.cdph.ca.gov/programs/SIDS/Documents/ChildCareProvSleepSPAN2011.pdf
AAP: https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KAKI, SUNDA BENITO
FACILITY NUMBER: 304313899
VISIT DATE: 06/23/2021
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LPA reviewed with applicant the following safe sleep best practices:
· Always place infants on their backs for sleeping
· Use only a tight-fitting sheet on the crib or play yard mattress
· Do not hang any items from the crib or above the crib
· Keep all items, including blankets, out of the crib or play yard
· Pacifiers may be used as long as they do not have items attached to them
· Infants should not be swaddled or have any items covering them while sleeping
· The temperature of the room should be comfortable enough for an adult to wear a t-shirt and not too hot or too cold

The applicant was given a pamphlet on Lead Exposure and was discussed with provider. Also provided was information about the E-Learning Modules available at https://ccld.childcarevideos.org. The Chaptered Legislation for AB 2084 (Nutritious Beverages) is available to view on the website at: http://ccld.ca.gov/res/pdf/12APX-11.pdf

LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

The facility was not in compliance for a Small Family Child Care Home with Title 22 Regulations at the time of inspection.



The following was observed and needs correction before a license can be issued:
1. Applicant need to fix the fence gates leading to the pool.

Proof of corrections, such as, pictures need to be submitted to Licensing Office before the due date of 06/30/2021. If an extension is needed, please submit a letter in writing before the due date.


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SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: KAKI, SUNDA BENITO
FACILITY NUMBER: 304313899
VISIT DATE: 06/23/2021
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A license will be issued after final review, in the event additional requirements are needed, the applicant will be notified.

An exit interview conducted where the report was reviewed with the applicant. Appeal Rights and the appeal rights process was discussed with the applicant. The applicant was informed all appeals must be in writing and received by the licensing office within 15 business days. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.



End of Report
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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