<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313899
Report Date: 04/26/2022
Date Signed: 04/26/2022 12:25:29 PM


Document Has Been Signed on 04/26/2022 12:25 PM - 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868



FACILITY NAME:KAKI, SUNDA BENITO & CHAUMONT, NICHOLASFACILITY NUMBER:
304313899
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 5DATE:
04/26/2022
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sunda Kaki and Chaumont Nicolas, LicenseesTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs), Stacy Torrence and Diana Valdez-Santana conducted an unannounced case management inspection of the facility on today's date due to receiving an application requesting an increase in capacity. LPAs met with licensees Sunda Kaki and Nicholas Chaumont, who guided analysts on a tour of the facility. Census was taken. There were three infants and two preschool children present. Currently there are two adult residents and four minor children living in the home. The applicants are requesting a Large Family childcare home license. Per applicants, operation hours will be Monday to Friday 7:00 AM to 6:00 PM and care and supervision shall be provided to children ages 0 months to 6 years old (Infant and Preschool). Applicants stated they are not currently registered with any Foster Care agency or holds a foster parent license. Applicants were reminded if changes to notify the licensing office.

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.

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 applicants have designated two bedrooms, one bathroom, and the covered patio as part of her day-care. Applicants have designated three bedrooms, one bathroom, living room, dining room, kitchen, attached garage, front yard, and backyard as off limit areas. Applicants have placed a child proof gate at the entrance of the hallway, leading to the daycare areas, ensuring the off-limit areas are inaccessible to children, during operation hours. The applicants acknowledged the children may never enter the off-limit areas. The applicants have a cell phone that is used for childcare. The applicants were informed if a cell phone is used for childcare, it must remain on the premises at all times during hours of operation. Applicants were informed and understands the home is to be free from smoking during hours of operation.

Continue on page (1 of 5)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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 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 & CHAUMONT, NICHOLAS
FACILITY NUMBER: 304313899
VISIT DATE: 04/26/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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 meets Title 22 regulations 102417(g)(5)

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. Applicants stated there are not weapons or firearms on the premises. LPAs advised applicants that when there are firearms 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 applicants and expires on 01/2022 and 01/2023. Applicants completed the 8-hour Preventative Health Practices, Nutrition Course, and Lead Poisoning on 01/2022 and 05/27/2021.

Infant room was observed to have napping items. Applicants provide milk for the infants. Diapers/wipes/lotions are provided by the parents.

The following was discussed with applicants:
Applicants were informed that individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to initial presence in a licensed Family Child Care Home. LPA provide applicant with website for Live-Scan locations oag.ca.gov/fingerprints/locations for all adult complete LIC 9163. If an 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.
Continue on next page (2 of 5)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
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 & CHAUMONT, NICHOLAS
FACILITY NUMBER: 304313899
VISIT DATE: 04/26/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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 applicants 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 LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Home, children’s forms/records, facility forms/records, and information to be posted.

In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an adult who has a valid and current Pediatric First Aid and CPR certification, TB clearance along with a valid criminal record clearance associated the facility license.

Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated. Fire extinguisher type 2A-10 BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed.

Applicanst were 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.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option


Continue on next page (3 of 5)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
Page: 3 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 & CHAUMONT, NICHOLAS
FACILITY NUMBER: 304313899
VISIT DATE: 04/26/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPAs reviewed with applicants the following safe sleep best practices:
Safe to Sleep Campaign: https//safesleep.nichd.nih.gov/materials
· 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 applicants were 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/cdssprograms/community-care-licensing/caregiver-background
check/guardian

Hard copy and link of Child Care Providers Guide to Safe Sleep provided to licensee:
https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf.

LPAs discussed the following information with the Applicants, during the exit interview:
Criminal Record Statement: Applicants were 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.

Continue next page (4 of 5)
SUPERVISOR'S NAME: Thuy HoTELEPHONE: (714) 287-8515
LICENSING EVALUATOR NAME: Stacy TorrenceTELEPHONE: (714) 300-3599
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
Page: 4 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 & CHAUMONT, NICHOLAS
FACILITY NUMBER: 304313899
VISIT DATE: 04/26/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Safe Sleep : LPAs discussed the safe sleep regulations with applicants 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 the applicants 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information , see PIN 22-02-CCP. 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.



OTHER INFORMATION AND FORMS PROVIDED: Capacity Handout for a Large Family Child Care Home. Applicant shall maintain LIC 9227 form in the infant file.

LPAs reviewed Title 22 Regulation Section 102423 Personal Rights including but not limited to: no intimidation, no humiliation, and no corporal punishment.

The facility was in compliance for a Large Family Child Care Home with Title 22 Regulations at the time of inspection.

A license will be issued after final review, in the event additional requirements are needed, the applicant will be notified.

An exit interview conducted, and report was reviewed with Sunda Kaki and Nicolas Chaumont. Appeal Rights and the appeal rights process was discussed with the applicant. Applicants were informed all appeals must be in writing and received by the licensing office within 15 business days.

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

DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5