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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617929
Report Date: 02/27/2020
Date Signed: 02/27/2020 09:52:32 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:HOLUB, JANETFACILITY NUMBER:
343617929
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 1DATE:
02/27/2020
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Janet HolubTIME COMPLETED:
10:15 AM
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At 8:15 a.m. on Thursday, February 27th, 2020, Licensing Program Analyst (LPA) Karyn Guerra met with the licensee, Janet Holub, for the purpose of an unannounced annual random inspection. All individuals subject to criminal background review have obtained a criminal record clearance. Hours of operation for the facility are 7:30 a.m.-5:00 p.m., Monday thru Friday. Upon arrival at 8:15 a.m., LPA observed a census of 1 infant child.

At 8:20 a.m., LPA reviewed children’s files and observed immunization records and signed Family Child Care Home Notification of Parents' Rights in 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 in person EMSA CPR and First Aid certification was verified and expires 5/2020. LPA observed AB 1207 Mandated Reporter Training certificate expiring 2/2020. Licensee stated that she will be renewing the certificate this weekend.

At 8:40 a.m., 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 the master bedroom and bathroom, office, son’s bedroom, side room, and mother's house in the backyard. 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. Weapons in the home are appropriately stored per title 22 regulations. There are no bodies of water on the premises. Toxic and hazardous items are inaccessible to children. Outdoor play space is fenced.


Report continues on 809-C.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
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: HOLUB, JANET
FACILITY NUMBER: 343617929
VISIT DATE: 02/27/2020
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This provider is currently not providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed. 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: https://www.ada.gov/childqanda.htm.

LPA verified that the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates. LPA provided and discussed the Safe Sleep in Child Care and Effects of Lead Exposure brochures.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and shall remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for child care updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. The licensee's signature on this form acknowledges receipt of this form.



In the areas that were evaluated, no deficiences were observed during the time of inspection.
SUPERVISOR'S NAME: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2020
LIC809 (FAS) - (06/04)
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