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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343617929
Report Date: 07/22/2021
Date Signed: 07/22/2021 10:55:28 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: 7DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Janet HolubTIME COMPLETED:
11:15 AM
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At 9:45 a.m. on Thursday, July 22nd, 2021, Licensing Program Analyst (LPA) Karyn Guerra met with Licensee, Janet Holub for the purpose of a required 1 year inspection. The Licensee's assistants were also present during the inspection. A COVID-19 risk assessment was conducted via telephone prior to entering the facility. 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, LPA observed a census of 6 preschool aged children and one school aged child.

At 9:47 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, 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. Firearms are appropriately stored. Toxic and hazardous items are inaccessible to children. Fireplace is blocked to prevent access by children. Outdoor play space is fenced.

At 10:15 a.m., LPA reviewed children’s and staff 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. Current in person EMSA CPR and First Aid certification was verified and expires June 12th, 2022, and AB 1207 Mandated Reporter Training was verified and expires March 3rd, 2022.


Report continues on 809-C.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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: HOLUB, JANET
FACILITY NUMBER: 343617929
VISIT DATE: 07/22/2021
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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.

No infants are enrolled in care at the facility. LPA verified that the annual fees are current.

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.

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 deficiencies were observed at the time of the inspection.
SUPERVISOR'S NAME: Seychelle De LucaTELEPHONE: (916) 263-5719
LICENSING EVALUATOR NAME: Karyn GuerraTELEPHONE: (916) 216-7790
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
LIC809 (FAS) - (06/04)
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