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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 125407874
Report Date: 02/10/2022
Date Signed: 02/10/2022 01:24:52 PM

Document Has Been Signed on 02/10/2022 01:24 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: 7CENSUS: 5DATE:
02/10/2022
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kehaulani RobertsTIME COMPLETED:
01:45 PM
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A Case Management - Licensee Initiated inspection was conducted at the facility by Licensing Program Analyst (LPA) Kiriko Lynch in response to an capacity increase Family Child Care Home (FCCH) application received by the Department on 02/03/2022. During today's visit, the facility was operating within the licensed capacity and ratio requirements. The facility was toured and inspected. No deficiencies were observed. Fire clearance was received by Licensing on 02/08/2022, and is granted per fire clearance contingency of garage storage items removal. LPA observed garage at the time of the visit, and did not observe any storage items as noted in the fire clearance. Licensee is requesting to add garage to the on-limits area of the FCCH, kitchen/laundry room as pass-through areas to the garage, and all bedrooms in off-limits areas.

License for the Large FCCH is approved today, 02/10/2022.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Kiriko Lynch
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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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