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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700249
Report Date: 01/07/2022
Date Signed: 01/07/2022 11:27:03 AM

Document Has Been Signed on 01/07/2022 11:27 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:KOHLER FAMILY CHILD CAREFACILITY NUMBER:
367700249
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
01/07/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Laura KohlerTIME COMPLETED:
11:43 AM
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Licensing Program Analyst (LPA) Thompson-Miller met with Applicant, Laura Kohler, who guided analyst on a tour of the facility for a Prelicensing Inspection. This is a two story 5 bedroom, 3 bathroom home with kitchen, dining, family room, laundry room and garage. There is no pool/spa or body of water on the premises. There is large Trampoline in the back yard. Family members residing in the home include 3 adults (applicant, applicant spouse, adult son) and two children. Days/hours of operation are Monday through Sunday 6AM to 4:30AM. Incidental Medical Services (IMS) policy was discussed.

Physical Plant: Main care is the family room (at entrance). Children use the bathroom next to the kitchen. Off limit areas include the entire upstairs (Bedroom #2 , #3 , #4, #5, bathroom #2 and #3), pantry (key lock), laundry/garage (key lock), pantry (key lock), Bedroom #1 downstairs (key lock). The home was inspected inside and out for safety, clean and orderly, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents/cleaning compounds (pantry), medicines (pantry) and hazardous items (sharp knives in pantry in a container) that can pose a danger to children. Fire place is screened and blocked. There are safe age appropriate toys, play equipment and materials. The smoke detector and Fire Extinguisher (2A10BC) are in operable condition. Stairs have a gate. Per Applicant no one smokes in the home. Electrical outlets are inaccessible, no baby bouncers saucer chairs, or any recalled and or prohibited toys or sleep/play equipment were observed on the premises. There is a designated area for ill children as necessary in family room. Per Applicant there are no weapon/firearms in the home. The facility sketch is complete and current, there is working telephone (landline, cell). LPA explained to conduct Fire/earthquake drills every six months and document. LPA provided the Roster and explained how to complete and maintain current. Age appropriate napping (cots, playpen, crib) equipment.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KOHLER FAMILY CHILD CARE
FACILITY NUMBER: 367700249
VISIT DATE: 01/07/2022
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Bathroom: Shower, no tub. The following are inaccessible: Sharp items, mouthwash, shampoo, razor, nail polish. Toilet and faucet is clean and operable.

Kitchen: Sharp utensils, open bottles or alcohol are inaccessible. If food is brought from the children’s home, the container shall be labeled with the child’s name and properly stored or refrigerated. The home has a clean and fully stocked refrigerator/freezer. Cleaning supplies are in pantry (off limit). No chemicals in the kitchen were observed to be accessible. Breakfast, lunch, dinner and snacks will be provided.

Outdoor: Per Applicant the Trampoline is for the family only, not for child care (Declaration provided). The backyard has the following inaccessible lawn mower, gardening tools, poisonous plant, thorn trees, cactus. The backyard is completely fenced (left and right side fenced). There is no body of water. There is two cats and two dogs (pets will be kept upstairs).

Advisory/Other: First Aid kit was observed with supplies (thermometer) readily available. CPR/First Aid expire 10/16/2023. Preventative Health and Safety (Nutrition, Lead Poisoning), Mandated Reporter expire 11/27/2023. Electrical outlets are inaccessible. There are no window cords accessible to children. Child nap on cots.

Documents Provided and or Discussed: Fire Drill Log, Roster, Licensing Postings, Safe Sleep and Lead Poisoning flyer's, COVID-19 posters and CDPH Mandate. Applicant stated she will obtain child care insurance later.
Names of all adults living in the home: All adults living/residing in the home are fingerprint cleared and associated.

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

SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KOHLER FAMILY CHILD CARE
FACILITY NUMBER: 367700249
VISIT DATE: 01/07/2022
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The following was discussed with the Applicant:
Mandatory licensing forms for the children’s files, facility forms/records, and information to be posted in the family child care home; Requirements to conduct fire and disaster drills once every six months and record it; Role and responsibilities of being a mandated reporter (www.mandatedreporterca.com) were reviewed; Applicant reminded that 100% supervision is required at all times to children in care; Applicant made aware that it is his/her/their responsibility to know the regulations as well as anyone who assists in providing care; Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified; Regulation prohibits the smoking of any kind during the operation of the day care. Per Applicant no on smokes in the home. The "Notification of Parent's Rights" poster must be posted in an area of the home accessible to parents. Licensee advised how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov .

Applicant advised of the requirement to report Unusual Incidents. Licensee informed to utilize the Unusual Incident Report/Injury Report LIC624B when submitting the report to the department (email address on the website: www.unusualincidentreport@dss.ca.gov). A report shall be made to the department by telephone or fax during the department's normal business hours before the close of the next working day following the occurrence during the operation of family day care home. In addition, a written report shall be submitted to the department within seven days following the occurrence of any events specified above.



Applicant advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days whenever a licensing inspection is conducted. If a Type A deficiency is cited, a copy of the licensing report must also be posted for 30 days. The same report must be provided to parents/guardians of children newly enrolled at the facility during the next 12 months & licensee must obtain a signed Acknowledgement of Licensing Reports (LIC 9224) from parent/guardian & place it in each child's file. Copies of the reports must be provided to each parent when a Type A violation is cited along with Acknowledgment of Receipt of Licensing Reports LIC 9224. If these requirements are not met civil penalties per violation will be assessed.

Any duly authorized officer, employee, or agent of the Department shall, upon presentation of proper identification, shall inspect the facility. The Applicant shall permit the Department to inspect the family child care home, and to privately interview children or staff, to determine compliance with or to prevent violations of family child care laws or regulations, also enter and inspect any place providing personal care, supervision and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: KOHLER FAMILY CHILD CARE
FACILITY NUMBER: 367700249
VISIT DATE: 01/07/2022
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Prior to making alterations or additions to a family child care home or grounds, the Applicant shall notify the Department of the proposed changed, including, but not limited to, the following: Conversion of a garage (either attached or detached) into a "child care" room; Room additions to the family child care home. Any change from an area of the family child care home previously identified as "off limits" to an area where care and supervision will be provided to children in care. Applicant shall provide the Department with a copy of an inspection report when an inspection is required by the local building inspector as a result of the alteration, addition or construction.
Applicant 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.

LPAs discussed the safe sleep regulations with licensee name 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 Laura Kohler 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.

Before licensure the following must be completed:
1. Carbon Monoxide is required
2. Bedroom #1 and laundry room shall be inaccessible
3. Play house shall be free of chipped paint

Once corrections have been verified, the application for a small Family Child Care Home will be submitted for approval with a maximum capacity of 6 or 8 with parent notification. Applicant advised that all corrections are due within 30 days or the application may be withdrawn.

A notice of site visit was given. The On Duty Worker is available for questions at (661) 202-3318 Monday through Friday 8am-5pm.
Exit interview conducted and report was reviewed with Applicant Laura Kohler. This report was read and provided to Applicant Laura Kohler on this date.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Linda Thompson-Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4