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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 173010033
Report Date: 09/29/2023
Date Signed: 09/29/2023 10:06:17 AM

Document Has Been Signed on 09/29/2023 10:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BOHAN, NAHANI FCCHFACILITY NUMBER:
173010033
ADMINISTRATOR:BOHAN,NAHANIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 287-0551
CITY:KELSEYVILLESTATE: CAZIP CODE:
95451
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 5DATE:
09/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:31 AM
MET WITH:Nahani BohanTIME COMPLETED:
10:15 AM
NARRATIVE
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On 09/29/2023, an inspection was conducted at the facility by Licensing Program Analysts (LPA) Sebastian Phouthavong. During the course of an inspection, LPA toured the facility inside and out and met with Licensee, Nahani Bohan. LPA observing five being supervised by Licensee, operating within the License capacity ratio. On 07/27/2023, licensee admitted that during a pervious personal emergency, the daycare children were left alone with staff that did not have a current Pediatric CPR and First Aid training certificate. Furthermore, a Staff member stated that they have supervised the daycare children without completing a Pediatric CPR and First Aid training and never obtain a current certificate; corroborating with the Licensee’s statement. On 08/04/2023, Licensee submitted two Pediatric CPR and First Aid training Certificates.

The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided.

Notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with the licensee, Nahani Bohan.

SUPERVISORS NAME: Leslie Lepori
LICENSING EVALUATOR NAME: Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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 09/29/2023 10:06 AM - It Cannot Be Edited


Created By: Sebastian Phouthavong On 09/29/2023 at 09:19 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BOHAN, NAHANI FCCH
FACILITY NUMBER: 173010033

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
102416(c)(b)

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102416(c)(b) A licensee of a large family day care home...ensure that at least one person who has a current certificate in pediatric first aid and pediatric cardiopulmonary resuscitation ... be available at all times when children are present at the facility....
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Licensee corrected the deficiency by submitting current valid Pediatric CPR and First Aid Certifications for herself and one staff member on 08/04/2023 to Community Care Licensing.

POC has been Cleared
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Based on Record Review Licensee’s staff member (S1) did not have a current Pediatric CPR and First Aid Certification when they were alone with day care children, which poses a potential health, safety or personal rights risk to persons in care.
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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:Leslie Lepori
LICENSING EVALUATOR NAME:Sebastian Phouthavong
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


LIC809 (FAS) - (06/04)
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