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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376300501
Report Date: 04/12/2022
Date Signed: 04/12/2022 11:44:19 AM

Document Has Been Signed on 04/12/2022 11:44 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, 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:
04/12/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH: Applicant Jennifer KloostermanTIME COMPLETED:
11:45 AM
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An Informal Conference was held in the Riverside Regional Office South East with Licensing Program Manager Pauline Beschorner, Licensing Program Analyst Otsanya Cameron and Applicant Jennifer Kloosterman.

The purpose of this meeting is to address Applicant's need to ensure the health and safety of children in her care in addition to understanding Community Care Licensing Division's rules and regulations. Applicant was previously licensed and an application has been submitted for a new location.

LPM and LPA conducted a Community Care licensing Orientation. The following was discussed: Personal Rights, Basic Operating requirements, Staffing requirements, Capacity, Reporting & Notification Requirements, Unusual Incident Reports, Parent Notification Requirements, Physical Plant, Safe Sleep Regulations, Covid 19 regulations, Applications process and and Other General information.

To report an Unusual Incident Report (UIR), please fax/scan a completed UIR form (within 24 hours of incident occurring), to the Unusual Incident Reporting email mailbox: UnusualIncidentReportsDO10@dss.ca.gov or fax to 951-782-4985.

LPA provided copy of PIN 20-20-CCLD provides guidance for providers on how to access Guardian and gives an introduction of the agency functionality in Guardian.

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.
SUPERVISORS NAME: Pauline Beschorner
LICENSING EVALUATOR NAME: Otsanya Cameron
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2022
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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