<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618155
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:16:11 PM


Document Has Been Signed on 10/15/2024 02:16 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:ROTHFIELD, KEIKOFACILITY NUMBER:
343618155
ADMINISTRATOR:SILVERT, KEIKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 202-0474
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:14CENSUS: 0DATE:
10/15/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Keiko RothfieldTIME COMPLETED:
02:35 PM
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 10/15/2024 at approximately 1:30 PM, Licensing Program Analyst (LPA) Michelle Perez met with Licensee, Keiko Rothfield for an unannounced inspection. During the inspection there was a census of 0 CHILDREN supervised by the licensee. All individuals subject to criminal background review have obtained a criminal record clearance. Facilities hours of operation are Monday through Thursday 8:30AM to 12:30PM.

A health and safety inspection was conducted in the areas accessible to children. The off-limit areas are include: All bedrooms, garage & side yard. 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 fireplace that is barricaded. The licensee stated that there are no firearms or bodies of water on the premises.

SUPERVISOR'S NAME: Amanda BlesiTELEPHONE: (916) 263-5824
LICENSING EVALUATOR NAME: Michelle PerezTELEPHONE: (916) 594-3812
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROTHFIELD, KEIKO
FACILITY NUMBER: 343618155
VISIT DATE: 10/15/2024
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
LPA observed a children's roster and fire drill log, the last fire drill was conducted 9/2024. Licensee's has current CPR/First aid, which expires 6/2025. Licensee’s Mandated Reporter Training expires 10/2024. Licensee understands both training’s must be completed every two years. LPAs reviewed records of children’s files, all which contained the required documentation.

Incidental Medical Services (IMS) policy was discussed. NO children on medication. 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 safe sleep regulations.

SUPERVISOR'S NAME: Amanda BlesiTELEPHONE: (916) 263-5824
LICENSING EVALUATOR NAME: Michelle PerezTELEPHONE: (916) 594-3812
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROTHFIELD, KEIKO
FACILITY NUMBER: 343618155
VISIT DATE: 10/15/2024
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
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: Amanda BlesiTELEPHONE: (916) 263-5824
LICENSING EVALUATOR NAME: Michelle PerezTELEPHONE: (916) 594-3812
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3