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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125407874
Report Date: 09/10/2021
Date Signed: 09/10/2021 05:25:46 PM

Document Has Been Signed on 09/10/2021 05:25 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:ROBERTS, KEHAULANI FAMILY CHILD CARE HOMEFACILITY NUMBER:
125407874
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
09/10/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Kehaulani RobertsTIME COMPLETED:
06:00 PM
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A prelicensing inspection was conducted today by Licensing Program Analyst (LPA) Kiriko Lynch. The applicant is requesting a license for a small family child care home with a capacity to serve up to eight children. Services will be provided Monday - Friday 7:30 a.m. to 5:30 p.m., and by appointment. The applicant understands that child care must be provided in the primary residence of the applicant. The residence is a 3 bedroom/1.5 bath home. Applicant stated she understands all adults residing or working at the home in care of children must have a criminal background clearance on file with Licensing. Off-limits areas include: master bed/bath, daughter's bedroom, laundry room, garage, and are made inaccessible by gates, fencing, and/or child-safety knobs/latches/locked doors. The home appears to be clean and orderly. There is a working telephone. The sharp knives, cleaning supplies, medicines, and other hazards are stored in inaccessible areas out of the reach of children. The children in care will have access to age appropriate toys and equipment. The home is equipped with a working smoke detector, carbon monoxide detector, and fire extinguisher per regulatory requirements. Home utilizes forced air heating. Fireplace is barricaded by fencing, and not used during child care hours. Backyard play area is fenced, and there are no bodies of water on the property. Applicant stated she understands that children require 100 percent supervision in all unfenced/partially fenced outdoor areas. Applicant stated she understands the requirement to contact Licensing if any major construction is done. Applicant stated she will utilize affidavit form until obtaining liability insurance. Proof of control of the property is on file. Applicant stated she understands emergency drills must be conducted at least once every six months, and the date documented.

Report continues on next page
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Kiriko Lynch
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: ROBERTS, KEHAULANI FAMILY CHILD CARE HOME
FACILITY NUMBER: 125407874
VISIT DATE: 09/10/2021
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Children's records to be maintained at the facility were reviewed with applicant. Applicant stated she understands the facility roster is to remain current at all times. Unusual Incident Report procedures were explained to include notification before close of next business day, and follow up with written report within seven days to Licensing. The applicant stated she will remain current on Pediatric CPR and First Aid certification, and it expires 11/30/22, and mandated reporter training certification expires 01/06/23. The applicant stated she understands the capacity and ratio, and care and supervision requirements for the small family child care home. The applicant shall be present in the home per regulatory requirements, and shall ensure that children in care are supervised by an adult cleared through Licensing per background clearance regulatory requirements, with current Pediatric CPR and First Aid certification, and other requirements as necessary per regulatory requirements. The applicant stated she understands that children in care may only be transported by adults with a criminal record clearance and are never to be left unattended in a vehicle. The applicant stated she understands the responsibility to have knowledge and understand the laws and regulations for the operation of a family child care home. Forms and regulations, and child care updates and provider information notices (PINs), may be obtained from the website: www.cdss.ca.gov/inforesources/child-care-licensing. The Megan's Law web site was provided: www.meganslaw.ca.gov. The applicant stated she understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice. This report, as well as the Safe Sleep Regulations, and Covid-19 risk mitigation documents and postings were reviewed and discussed with the applicant. All licensing reports are public information and must be made available upon request for at least three years. Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

Facility is licensed today 09/10/21.

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Kiriko Lynch
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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