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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623133
Report Date: 06/22/2021
Date Signed: 06/22/2021 02:42:38 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, DEVIKAFACILITY NUMBER:
343623133
ADMINISTRATOR:KOHONA, DEVIKAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 508-5935
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY:14CENSUS: 10DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Devika Kohona, LicenseeTIME COMPLETED:
02:55 PM
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At 1:45 p.m., Licensing Program Analyst (LPA) Joleen Kenney met with the Licensee, Devika Kohona, for the purpose of an unannounced annual inspection. All individuals subject to criminal background review have obtained a criminal record clearance. During today's inspection LPA observed 10 children supervised by the Licensee and the Licensee's spouse.

A health and safety inspection was conducted in all areas accessible to children. Off-limit areas includes the master bedroom and bathroom, bedroom #1, laundry room and garage. Licensee acknowledged that children must never enter these off limit areas. LPA observed the required postings, a working phone, fire extinguisher, and smoke and carbon monoxide detectors. Licensee stated there are no weapons in the home. Licensee understands children must have 100% supervision in unfenced areas. Toxic and hazardous items are inaccessible to children.

At 2:00 p.m., all children’s files were reviewed. LPA observed immunization records and signed Family Child Care Home Notification of Parents' Rights in children's files. LPA observed a current children's roster. Fire and disaster drills were discussed with the Licensee. The Licensee stated that she understands that the fire drills must be documented at least every six months. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu were verified. Licensee has an in person EMSA CPR and First Aid certification. Licensee has completed the Mandated Reporter Training. Licensee understand that the training is required to be completed once every two years and the training is accessible at www.mandatedreporterca.com.

This Licensee does not currently provide IMS services to children in care. 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.
Report continues on 809-C.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Joleen KenneyTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
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: KOHONA, DEVIKA
FACILITY NUMBER: 343623133
VISIT DATE: 06/22/2021
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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 notified the Licensee that the annual fees are currently due.

LPA discussed Safe Sleep Regulations with the Licensee. LPA reviewed Infant Individual Sleeping Plan (LIC9227) for children under 12 months of age and sleep logs for the children under two years of age.

This facility evaluation report was reviewed and discussed with the licensee. A Notice of Site Visit was provided and should remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, current forms, legislation and regulation information. The licensee's signature on this form acknowledges receipt of this form.



In the areas that were evaluated, no deficiencies were observed or cited during todays visit.
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Joleen KenneyTELEPHONE: (916) 799-9668
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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