393622304-7-28-2023-53-CC-CBEY-CU72NE-20230728173237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 393622304
Report Date: 07/28/2023
Date Signed: 07/28/2023 05:32:45 PM

Document Has Been Signed on 07/28/2023 05:32 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	SIKORA-LIU, KAJA		FACILITY NUMBER:	393622304
ADMINISTRATOR:	SIKORA-LIU, KAJA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(408) 598-3607
CITY:	TRACY	STATE: CA	ZIP CODE:	95377
CAPACITY:	14	CENSUS: 2	DATE:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Kaja Sikora-Liu		TIME COMPLETED:	03:30 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 July 28, 2023, at 12:00 pm Licensing Program Analyst (LPA) Corina Beckby met with Licensee Kaja Sikora-Liu for the purpose of an unannounced annual inspection. LPA provided and reviewed the Family Child Care Home Entrance Checklist. LPA observed 2 children being supervised by Licensee. Not all individuals subject to criminal background review have obtained a criminal record clearance. Facility days and hours of operation are Monday - Friday from 8:30 am to 3:30 pm. Licensee guided LPA on a tour of the facility and a health and safety inspection was conducted in all areas accessible to children. The off-limits areas include the second floor, garage and backyard where the pool is located. Licensee acknowledges that children may never enter the off limit areas. LPA observed the required postings, a fully charged fire extinguisher, and smoke and carbon monoxide detectors. Per Licensee, there are no weapons in the home. Licensee has a pool. LPA walked the perimeter of the fenced pool to ensure stability of fence. The pool fence does not meet Title 22 regulations 5 feet fence around the pool and self-latching gate. Toxic and hazardous items are inaccessible to children. LPA reviewed 1 child’s file. A current children’s roster and fire drill was observed. LPA discussed the requirement of renewing CPR and mandated reporter training every 2 years. Licensee’s CPR is current and expires 8/07/23. Mandated reporter training could not be verified. The training can be renewed at mandatedreporterca.com. To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. (Report continues LIC809-C)

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina Beckby	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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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Document Has Been Signed on 07/28/2023 05:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIKORA-LIU, KAJA	FACILITY NUMBER: 393622304
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

102417(g)(5)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (5) All licensees shall ensure the inaccessibility of pools (in-ground and above-ground), fixed-in-place wading pools, hot tubs, spas, fish ponds and similar bodies of water through a pool cover or by surrounding the pool with a fence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the gate to the pool does not self latch, the mesh is ripped and the fence is not at least 5 feet high, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2023
	Plan of Correction
1 2 3 4	Licensee will call contractor to get an estimate of installing a new fence and workabe gate.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina Beckby	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIKORA-LIU, KAJA	FACILITY NUMBER: 393622304
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1596.8662(b)(1)

Administration of Child Day Care Licensing

(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that both Licensee and assistants Mandated Reporter Certficates have expired, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/28/2023
	Plan of Correction
1 2 3 4	Licensee will email a copy of certificates to LPA by or before due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina Beckby	TELEPHONE: (916) 591-1072
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIKORA-LIU, KAJA	FACILITY NUMBER: 393622304
	VISIT DATE: 07/28/2023

NARRATIVE

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If you have any questions regarding the process or CARE tools, please send email inquiries 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.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina Beckby	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: SIKORA-LIU, KAJA	FACILITY NUMBER: 393622304
	VISIT DATE: 07/28/2023

NARRATIVE

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LPA informed Licensee, Kaja Sikora-Liu, that this report dated 7/28/2023, documents a Type A citation that is an immediate Health and Safety, or Personal Rights risk to persons in care. In addition, a Type B citation was issued that is a potential Health and Safety, or Personal Rights risk to persons in care. A separate 809D is issued for each deficiency. Upon receipt of a Type A deficiency licensee shall post the report for 30 days in addition to the Notice of Site Visit and provide copies of the licensing report to parents/guardians of children in care at the facility. This report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months and licensee will obtain a signed Acknowledgment of Licensing Reports (LIC9224) from parent/guardian and place it in each child's file. If these requirements are not met, civil penalties will be assessed.

An Exit interview was conducted, and the report was reviewed with Licensee, Kaja Sikora-Liu. LPA posted a notice of site visit. Licensee understands the Notice must remain posted for 30 days and that a failure to comply with posting requirements shall result in an immediate civil penalty of $100. Appeal Rights were provided. 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.

SUPERVISOR'S NAME: Bettina Engelman	TELEPHONE: (916) 263-5820
LICENSING EVALUATOR NAME: Corina Beckby	TELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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