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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313605150
Report Date: 02/20/2020
Date Signed: 02/20/2020 10:55:27 AM

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:KLEBOFSKI, MICHELLEFACILITY NUMBER:
313605150
ADMINISTRATOR:KLEBOFSKI, MICHELLEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 259-4111
CITY:ROCKLINSTATE: CAZIP CODE:
95765
CAPACITY:14CENSUS: 0DATE:
02/20/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michelle KleboskiTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Jeremey McClain met with Licensee Michelle Klebofski for an unannounced annual inspection. No children were present during the inspection today. Licensee stated there aren’t new residents in the home. All adult residents have criminal record clearances.

LPA toured areas of the home accessible to the children. The upstairs of the home is off-limits.

LPA observed current CPR/First Aid certificate which expires 02/08/2022. LPA observed the following posted: a license, a Parents' Rights Poster and an Emergency Disaster Plan. LPA reviewed children's records for completeness, as well as the client roster. Licensee provided proof of immunizations for MMR, Pertussis, and influenza.

LPA discussed the Provider Information notice 19-08-CCP which discusses new immunization requirements from the Department of Public Health. LPA provided licensee with and updated CPDH 286 for recording children’s immunizations.

A health and safety inspection of the interior and exterior of the home was conducted. LPA observed that hazardous items (detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care) are properly stored out of children's reach. LPA observed a fireplace that was properly screened, and stairs were properly barricaded. There is a working telephone in the home. Licensee stated that there are no weapons in the home. Licensee’s fire extinguisher, carbon monoxide and smoke detector meet regulation. LPA observed fire drills documented on a calendar, indicating that the licensee is conducting disaster drills at least once every 6 months. Toys appear to be safe and in working order. The backyard is fenced. LPA did not observe any bodies of water on the premises.
REPORT CONTINUED ON THE FOLLOWING PAGE.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
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 2
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: KLEBOFSKI, MICHELLE
FACILITY NUMBER: 313605150
VISIT DATE: 02/20/2020
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Incidental Medical Services (IMS) policy was discussed and the licensee is currently has an IMS plan on file. 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

AB1207 Mandated Reporter training was observed to be current through 01/03/2022. LPA provided Licensee with website: http://childcare.mandatedreporterca.com/ and reminded the licensee that the training must be completed once every two years.



LPA discussed recent changes in licensing requirements. LPA also provided licensee with CDSS’ AB 2370 brochure regarding the effects of lead exposure.

No deficiencies of Title 22 regulations were observed during today’s inspection



This report was reviewed with licensee, and an exit interview was conducted. A Notice of Site Visit was provided and should remain posted for 30 days.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Jeremey McClainTELEPHONE: (916) 216-7801
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020
LIC809 (FAS) - (06/04)
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