313614524-5-5-2023-03-CC-MPAL-CRJP4C-20230505105856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 313614524
Report Date: 05/05/2023
Date Signed: 05/05/2023 10:59:07 AM

Document Has Been Signed on 05/05/2023 10:59 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME:	COOK, KIMBERLY		FACILITY NUMBER:	313614524
ADMINISTRATOR:	PHILLIPS, KIMBERLY & CATHY		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(530) 888-9776
CITY:	AUBURN	STATE: CA	ZIP CODE:	95603
CAPACITY:	14	CENSUS: 11	DATE:	05/05/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Cathy Phillips and Kimberly Cook		TIME COMPLETED:	11:15 AM

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

On May 5th, 2023 at approximately 9am, Licensing Program Analyst (LPA) Michelle Pascual met with Licensees, Cathy Phillips and Kimberly, for an unannounced annual / one year inspection. During the inspection there was a census of 11 being supervised by the licensees and assistant. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are 7am to 5:30pm.

A health and safety inspection was conducted in the areas accessible to children. The off-limit areas are include: Master bed/bath, fenced animal areas, all outdoor buildings and property west of driveway. Licensee understands that children may never enter these off-limits areas. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. LPA observed all required postings. LPA observed home was safe, orderly, and free of hazards. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA observed a wood burning stove within the home and it is barricaded. The licensee stated that there are no firearms or bodies of water on the premises.

LPA observed a children's roster and fire drill log, the last fire drill was conducted February 2023. Licensee's has current CPR/First aid, which expires May 2023. Licensee’s Mandated Reporter Training expires 03/2025. Licensee understands both training's must be completed every two years. LPAs reviewed records of children’s files, all which contained the required documentation.

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Michelle Pascual	TELEPHONE: (916) 594-3812
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833

FACILITY NAME: COOK, KIMBERLY	FACILITY NUMBER: 313614524
	VISIT DATE: 05/05/2023

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

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

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.

Licensee is aware of and/or practicing safe sleep regulations.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

No deficiencies were cited during today’s inspection.

Exit interview conducted and report was reviewed with the Licensee. A notice of site visit was provided and must remain posted for 30 days

SUPERVISOR'S NAME: Keven Peters	TELEPHONE: (916) 263-5728
LICENSING EVALUATOR NAME: Michelle Pascual	TELEPHONE: (916) 594-3812
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2