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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393622304
Report Date: 09/05/2019
Date Signed: 09/05/2019 01:52:14 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:SIKORA-LIU, KAJAFACILITY NUMBER:
393622304
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 2DATE:
09/05/2019
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Kaja Sikora-LiuTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Alecia Sifuentes met with licensee Kaja Sikora-Liu for the purpose of a Capacity Increase from 8 to 14 children. LPA Sifuentes toured all areas of the two story home that are accessible to children. Also present during today’s inspection was Licensees husband Ying Liu, who has been finger print cleared through Community Care Licensing. Licensee stated there are no new residents in the home since licensure.

Off-limit areas include: Entire second floor and garage. Licensee acknowledged that children may never enter these off-limit areas. LPA observed a current roster of the enrolled children and fire drill log. The Fire Safety Inspection Clearance has been received from the Tracy Fire department on 8/6/2019 and the home has been cleared for up to 14 children. The backyard is fenced and has a pool. The pool is surrounded by fencing that meets regulation and there are no windows or doors that provide direct access to the pool area. LPA checked gate to be self-closing and latching. Licensee understands that prior to making alterations or additions to the home or grounds, the licensee shall notify the Department of the proposed changes.

Large family child care home capacity limitations were reviewed during today's visit. Licensee acknowledges that when there is no assistant present, facility will revert back to the small capacity. Licensee acknowledges that children residing in the home under the age of 10 years shall be included in capacity. LPA observed a current CPR/First Aid certificate which expires on 8/31/2021.

Effective today's date, 9/5/2019, LPA will approve the capacity increase to serve up to either 14 children, two (2) of which must be at least 6 years of age and no more than three (3) may be infants; or 12 children, four (4) of which may be infants. Infants are children under the age of 2.

In the areas that were evaluated, no deficiencies were observed at the time of the visit.
Exit interview conducted. Notice of site visit posted.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Alecia SifuentesTELEPHONE: (916) 917-9202
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2019
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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