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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300501
Report Date: 04/06/2022
Date Signed: 04/06/2022 01:05:50 PM

Document Has Been Signed on 04/06/2022 01:05 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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME:KLOOSTERMAN FAMILY CHILD CAREFACILITY NUMBER:
376300501
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
04/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:07 AM
MET WITH:Applicant- Jennifer KloostermanTIME COMPLETED:
01:21 PM
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On date at 10:07 AM, Licensing Program Analysts (LPAs) Otsanya Cameron and Jessica Rubio arrived at the facility to conduct a pre-licensing inspection. Present during this inspection were: Applicant Jennifer Kloosteman. The home is with 5 bedrooms, 3 bathrooms, with attached garage. LPA toured the facility, inside and out with Applicant and the following was observed and/or discussed:

· Per Applicant, off-limit areas include: Garage , Complete second floor, Laundry Room . Off-limit areas have knob covers and barricades, making them inaccessible to children.
· Normal hours of operation will be: M-F 7am-9pm
· Smoke detectors and Carbon Monoxide detectors were tested by the applicant during this inspection and were in working order.
· There is central heating and air conditioning.
· The fire extinguisher is a 2A 10 BC fully charged and met standards established by the State Fire Marshal.
· All hazardous items were observed to be inaccessible. Storage of poisons and toxins are inaccessible to children and will locked in the laundry room. Sharp items including kitchen knives, will be made inaccessible and stored.
· First Aid Kit is located in the Linen closet, and contains all required items. All hazardous items have been removed.
· No guns or weapons are stored in the facility as of this date. Applicant understands all guns, weapons and ammunition must be key locked separately and made inaccessible per Title 22 Regulations.
· Stairs are barricaded
· The fireplace is properly screened
· Clean, safe and age appropriate toys were observed.
· LPA observed a working telephone located at her residence. Applicant has a cellphone handy.
· There were no toxic plants inside or outside the facility observed at this time
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Otsanya Cameron
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KLOOSTERMAN FAMILY CHILD CARE
FACILITY NUMBER: 376300501
VISIT DATE: 04/06/2022
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· The outside activity area consists of: Play structure, Play house, small trampoline, bikes,
· There are no bodies of water observed on this date. LPAs did observe a built in spa located in the backyard that has been covered, emptied, and made inaccessible. Applicant understands all bodies of water including ponds, above ground pools and spas, in-ground pools and spas, and some fountains must be properly covered or fenced per title 22 regulations. The Department must be notified before and after installation of the bodies of water described. In addition, all wading pools or similar product must be emptied immediately after use and stored in an upright position when not in use.
· Applicant will be using her personal vehicles to pick-up and drop-off children. The vehicle is in safe operating condition.
· Verification of control of property is maintained by applicant
· Facility Sketch and Emergency Disaster Plan are posted.
· Pediatric CPR and First Aid Card expires 8/2022
· Mandated Reporter certificate expires 3/9/2024
· Preventive Health and Safety training, was completed on 12/2/2017. Lead component was completed 9/23/2020 and Nutrition component will be taken through YMCA or other program to meet requirement
· The applicant, Jennifer Kloosterman, confirmed there are no Registered Sex Offenders living in the facility and/or using the facility address for their mailing address.

This facility provides Incidental Medical Services (IMS). LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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

Applicant was reminded 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.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Otsanya Cameron
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KLOOSTERMAN FAMILY CHILD CARE
FACILITY NUMBER: 376300501
VISIT DATE: 04/06/2022
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LPA discussed the safe sleep regulations with [applicant, Jennifer Kloosterman] 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 [applicant, licensee, or facility representative] 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.

LPA reviewed with [applicant, Jennifer Kloosterman] the LIC 311A, Records To Be Maintained At The Facility, for child’s records, personnel records, administrative records, and documents to be posted.

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.

The following items were also reviewed with the applicant during inspection:
- Failure to meet the posting requirements shall result in an immediate $100 civil penalty.
- Documentation of fire & earthquake drills to be conducted every six months
- Responsibilities of being a mandated reporter and updating training every 2 years
- Personal rights of children in care, including no corporal punishment
- Responsibility to know the Title 22 Regulations for anyone providing care and supervision
- Capacity and Supervision requirements
- Inaccessibility of hazards must be constantly reassessed depending on the children in care
- Current facility phone numbers must always be on file with the licensing office
- Baby walkers, bouncy seats, exert-saucers and other similar items are prohibited
- Car seat law
- Smoking is prohibited in the facility while providing child care or transporting children
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Otsanya Cameron
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
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, 3737 MAIN STREET, STE 700
RIVERSIDE, CA 92501
FACILITY NAME: KLOOSTERMAN FAMILY CHILD CARE
FACILITY NUMBER: 376300501
VISIT DATE: 04/06/2022
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- Once licensed, the Notice of Site Visit must be posted at the entrance of the facility for a period of
30 days. If a serious violation is cited, a copy of the licensing report (LIC809/LIC9099) must also
be posted for 30 days. A civil penalty of $100 per violation will be assessed for noncompliance.
- Applicant was informed of their reporting requirements and is provided with the Regional Office’s Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov
-The Applicant can submit fingerprint transfer forms to associate new individuals or to disassociate someone from the facility at: Associations_Disassociations858@dss.ca.gov
- Access to forms & Title 22 Regulations for Family Child Care Homes online at www.ccld.ca.gov
- The Duty Officer is available to answer questions Monday – Friday 8:00am to 5:00pm at:
1-844-LET-US-NO (1-844-538-8766) and/or 951-782-4200.


Before licensure, the following needs to be corrected/completed:
1. Remove Supplements, Alcohol/wine from accessible areas.
2. Consider alternate location for Knives and sharp tools.
3. Consider additional Key lock on Laundry room door to keep hazardous items inaccessible.
once all 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. An additional Informal meeting at the regional office with Licensing Program Manager will be recommended before licensure. Applicant advised that all corrections are due within 30 days or the application may be withdrawn.

Exit interview conducted and report was reviewed with the applicant (Jennifer Kloosterman).
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Otsanya Cameron
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
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