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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015700436
Report Date: 09/26/2023
Date Signed: 09/26/2023 12:10:43 PM

Document Has Been Signed on 09/26/2023 12:10 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KYONE, TIFFANYFACILITY NUMBER:
015700436
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
09/26/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Tiffany KyoneTIME COMPLETED:
12:15 PM
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On 9/26/2023 Licensing Program Analyst (LPA)Melanie Otsuji, met with applicant Tiffany Kyone for an ANNOUNCED PRE LICENSING INSPECTION. The home was toured to conduct a Health and Safety Inspection. The applicant plans to operate the facility Monday through Friday from 8:00AM - 5:30PM.

The home is a single story single family home. The home is neat and clean with heating and ventilation for safety and comfort. The OFF LIMIT AREAS are the kitchen, dining room, garage, office, and all bedrooms, which will be inaccessible by closed and/or locked doors and visual supervision. There is also a child safety gate barricading the off limit areas from the on-limit areas. The ON LIMIT AREAS are the classroom, backyard and the bathroom in the hallway. Outdoor area will be the backyard. Yard is fenced in all around. There are toys and learning equipment which are age appropriate.

The home has a fully charged fire extinguisher, working smoke detector, working carbon monoxide detector, and working telephone. The applicant’s Health and Safety training is completed and CPR and First Aid certificate is current and expires 1/2025. The applicant completed and received a certificate in mandated reporter training on 8/22/2025. The applicant is in compliance with new immunization law which pertains to day care providers. Per applicant, there are no firearms in the home. A copy of the mortgage statement was reviewed and shows control of property. A packet of forms pertaining to the children’s files and facility files were reviewed and discussed.

See 809-C for continuance
SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KYONE, TIFFANY
FACILITY NUMBER: 015700436
VISIT DATE: 09/26/2023
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Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

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: http://www.ada.gov/childqanda.htm



LPA reviewed with licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant. Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

This home is recommended for a license with an effective date of today, 9/26/2023. Exit interview conducted and report was reviewed with the Applicant, Tiffany Kyone.

SUPERVISORS NAME: Wynn Norona
LICENSING EVALUATOR NAME: Melanie Otsuji
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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