343623133-5-17-2019-03-CC-JKEY-BC9W2L-20190517165430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 343623133
Report Date: 05/17/2019
Date Signed: 05/17/2019 04:55:01 PM

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:	KOHONA, DEVIKA		FACILITY NUMBER:	343623133
ADMINISTRATOR:	KOHONA, DEVIKA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(916) 508-5935
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	14	CENSUS: 0	DATE:	05/17/2019
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Devika Kohona, Licensee		TIME COMPLETED:	05:15 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	Licensing Program Analyst (LPA) Joleen Kenney met with Licensee Devika Kohona for the purpose of a pre-licensing inspection for a change of location. Licensee Kohona was currently licensed under facility #343623133. Licensee and Licensee's spouse live in the home and all adults have a criminal record clearance. Licensee owns the home and has provided a mortgage statement as proof of control of property. A health and safety inspection was conducted inside and out. The one story home has an front yard, 3 bedrooms, 2 bathrooms, living room, family room, kitchen, laundry room, garage and fenced backyard. The off-limits areas in the home will be master bedroom, master bathroom, bedroom #1, laundry room and garage. Off-limits areas will remain inaccessible to children. There is a fireplace in the home that is properly barricaded for the safety of the children in care. Toxic and hazardous items are inaccessible to children. Functioning smoke and carbon monoxide detectors and a fire extinguisher were observed in the home. Current pediatric CPR and first aid training was verified and expires at the end of 4/2020. The Licensee will attend an updated preventative health training that includes the one hour of nutrition. Licensee stated there are no weapons in the home. There is no pool at the home. No other bodies of water was observed at the home. Immediate Civil Penalty regulation deficiencies were reviewed. LPA discussed the Immunization Regulations SB 792, the requirement that all individuals working or volunteering at a licensed Child Care Home must have vaccinations against, Pertussis, Measles and Influenza. Proof of required vaccines have been obtained from Licensee. *Report continued on 809-C..*

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Joleen Kenney	TELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2019

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: KOHONA, DEVIKA	FACILITY NUMBER: 343623133
	VISIT DATE: 05/17/2019

NARRATIVE

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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

This facility evaluation report was reviewed and discussed with the Licensee. Records, postings and reporting requirements were discussed. Licensee was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

The Fire Marshall inspection was conducted on May 15, 2019 and few corrections were required.

Upon an approved fire inspection, the Licensee will be approved to serve up to fourteen 14 children with a qualified assistant, two (2) of which must be school age children, one at least age 6 years of age, one enrolled in kindergarten or older and no more than three (3) may be infants; or 12 children with a qualified assistant, four (4) of which may be infants. Infants are children under the age of 2 years.

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Joleen Kenney	TELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2019

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: KOHONA, DEVIKA	FACILITY NUMBER: 343623133
	VISIT DATE: 05/17/2019

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Licensee discussed the AB1207 Mandated Reporter training. This training is optional at this time because it is only available in the English language. LPA provided the Mandated Reporter training website www.mandatedreporterca.com.

Licensee understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Licensee understands that if anyone else works with the children, they must also obtain the following: EMSA certified CPR and first aid training, immunization for Measles, Pertussis and Influenza, and complete AB1207 Mandated Reporter Training.

Licensee understands that a current roster must be maintained and that a fire drill must be conducted and documented once every six months.

Licensee understands that her FCCH license is not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. LPA explained to Licensee that if she moves and wants to continue to provide care, she must submit a change of location application and have the new home inspected again.

Licensee understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within seven days to remain in compliance.

Licensee understands that if any structural changes are made to the home; licensing must be notified prior to construction. Licensee understands that if she wants to make any off-limit areas an ON-limits for children, she must notify licensing and LPA must do an inspection BEFORE children are allowed in the areas.

Licensee understands that children’s records are to be maintained according to Title 22 regulations, and be accessible to licensing for up to three years. Licensee understands that her License, Emergency Disaster Plan, and the Parents Rights Poster must be posted in the home. Licensee will post all required forms in the family room wall for parent review.

Report Continued on following 809-C...

SUPERVISOR'S NAME: Roxana Saravia	TELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Joleen Kenney	TELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2019

LIC809 (FAS) - (06/04)

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