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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 480111584
Report Date: 05/26/2022
Date Signed: 05/26/2022 03:13:09 PM


Document Has Been Signed on 05/26/2022 03:13 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:PREMYODHIN, SUPAB FCCHFACILITY NUMBER:
480111584
ADMINISTRATOR:PREMYODHIN, SUPABFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 426-0306
CITY:SUISUNSTATE: CAZIP CODE:
94585
CAPACITY:14CENSUS: 0DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Licensee Supab PremyodhinTIME COMPLETED:
03:20 PM
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A annual inspection was made to the facility by Licensing Program Analyst (LPA), Elpidia Hernandez Torres. A review of staff records on 05/25/22 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. There are currently three adults living in the home.

During today’s inspection the home and grounds were toured. The licensee was not supervising any children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 06:00AM to 06:00PM, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the four bedrooms in the home and were made inaccessible by door locking mechanisms. The home was clean and orderly, and was at a comfortable indoor temperature. There were safe toys and equipment available for children. There is a working telephone in the home. The licensee has current pediatric CPR and First Aid certification, which expire on 12/2023. Licensee wasn't able to produce an updated Mandated Reporter 1207 Certificate, an advisory note was issued. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. Poisons are not stored on the premises. The fireplace has been made inaccessible with a screen. There is a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The licensee stated there are no firearms and/or other dangerous weapons in the home, and none were observed during today's inspection. Three children's records were reviewed at 02:28PM; required emergency information was observed to be on file.
continued on 809-C
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PREMYODHIN, SUPAB FCCH
FACILITY NUMBER: 480111584
VISIT DATE: 05/26/2022
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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.

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-and-resources/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 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

A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Supab Premyodhin.

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/process.

SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2022
LIC809 (FAS) - (06/04)
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