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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313614524
Report Date: 06/09/2022
Date Signed: 06/09/2022 03:11:39 PM


Document Has Been Signed on 06/09/2022 03:11 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:COOK, KIMBERLYFACILITY NUMBER:
313614524
ADMINISTRATOR:PHILLIPS, KIMBERLY & CATHYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 888-9776
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:14CENSUS: 13DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Kimberly Cook TIME COMPLETED:
02:30 PM
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Around 1:50 pm Licensing Program Analysts (LPA) Lea Habtom and Jeremey McClain met with Licensee, Kimberly Cook, for the purpose of an unannounced required 1-year inspection. The licensee's assistant was also present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. At 1:55 pm LPA observed a total census of 13 children including 1 infant under 12 months, 1 infant over 12 months, 7 preschool children, and 4 school age children.

At 2:00 pm, Licensee guided LPA on a tour of the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include master bed/bath, fenced animal areas, all outdoor buildings & property west of driveway. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. LPA did not observe bodies of water at the facility. Toxic and hazardous items are inaccessible to children. Wood burning stove is barricaded by a gate to prevent access by children. There are no stairs in the home. Outdoor play space is fenced.

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. LPA reviewed children’s files. A current roster is being maintained and fire and disaster drills are documented. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current CPR and First Aid certification was verified and expires 5/2023, and AB 1207 Mandated Reporter Training was verified for the Licensee and expires 1/2024. (Report continues LIC809-C)
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:
DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/09/2022
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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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: COOK, KIMBERLY
FACILITY NUMBER: 313614524
VISIT DATE: 06/09/2022
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 LPA observed one play yards at the facility. Play yards were free of loose objects. Licensee stated she places infant children on their backs when they are napping. LPA reviewed infant sleep plan (LIC 9227) requirement with Licensee, and 15-minute observation checks of napping infants.

LPA discussed the safe sleep regulations with licensee 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 licensee 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

(FDCH is providing) This facility provides Incidental Medical Services – IMS but has no children currently on medication. 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 Famioy Child Care Homes Section 102417. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 513-0301 (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.ht
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Lea HabtomTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
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