394500999-1-5-2024-53-CC-SWIS-CZ7U65-20240105141745

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 394500999
Report Date: 01/05/2024
Date Signed: 01/05/2024 02:17:53 PM

Document Has Been Signed on 01/05/2024 02:17 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	DOUGLASS, KATHERYNE & GOMEZ, KAREN		FACILITY NUMBER:	394500999
ADMINISTRATOR:	DOUGLASS, KATHERYNE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(200) 200-2000
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95215
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	01/05/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Katheryne Douglass		TIME COMPLETED:	02:46 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/05//2024, Licensing Program Analyst (LPA) Stacey Williams met with Applicant Katheryne Douglass (A1) for the purpose of a pre-licensing inspection. Applicant will share licensure with her sister, Karen Gomez. LPA disclosed the purpose of the inspection and was granted entrance into the Family Childcare Home (FCCH). LPA provided the Entrance Checklist to A1. A1 stated that she will provide care Sunday through Saturday and will provide overnight care. All individuals subject to criminal background review have obtained a criminal record clearance verified by LPA accessing Guardian. On 10/27/2023, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. Applicant rents the home and provided a copy of a written statement from her parent indicating the home is being occupied by A1 and Co Licensee, Karen Gomez. LPA observed signed copies of the LIC9150 and LIC 9149 forms. The home was inspected by the Waterloo Morada Fire District on November 15, 2023, and was issued a fire clearance for a large family childcare license.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DOUGLASS, KATHERYNE & GOMEZ, KAREN	FACILITY NUMBER: 394500999
	VISIT DATE: 01/05/2024

NARRATIVE

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A health and safety inspection was conducted inside and outside of the FCCH. A1 accompanied LPA for the entirety of the tour. The FCCH is single story house that consists of Livingroom, family room, den, kitchen, laundry room, 4 bedrooms, 3.5 bathrooms, laundry room and a two- car garage. LPA verified that toxic and hazardous items were inaccessible to children in care. The back yard is fenced but applicant does not plan to use it. There is a pool in the back yard, which is surrounded by a 5ft wrought iron fence. There is one entry for the fencing that self-closes and latches. In addition, there is patio door from an off-limit bedroom suite that leads directly to the pool area. There is a 5 ft. wrought iron fence around the patio door with a gate that meets regulations that makes the body of water inaccessible from the bedroom suite. Applicant plans to use the unfenced front yard for children’s outside play space, and she understands that 100% supervision is required in unfenced areas. Applicant stated there are no firearms in the home.

A1 stated there is one pet cat and dog in the home. Licensee stated that neither pet will interact with children in care. The Off-limits areas of the FCCH are all bedrooms, living room, laundry room, the backyard and the garages. A1 understands that OFF-limit areas must remain inaccessible to children in care.

LPA observed a functioning smoke detector and carbon monoxide. LPA observed cleaners stored in the garage and laundry room which are designated as off limit areas. LPA observed knives stored in the kitchen and are inaccessible to children.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DOUGLASS, KATHERYNE & GOMEZ, KAREN	FACILITY NUMBER: 394500999
	VISIT DATE: 01/05/2024

NARRATIVE

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A 2A10BC fire extinguisher was observed in the home. A1 stated there are no firearms in the home.

LPA discussed Mandated Reporter Training with A1. Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees complete training as specified on Mandated Reporter duties and to renew training every 2 years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at http://www.mandatedreporterca.com. The training is currently provided in English and Spanish. A1 has a current Mandated Reporter Training Certificate which will expire on 8/2025. Current Pediatric CPR and First Aid training was verified for A1 and expires on 5/2024. Completion of Preventative Health and Safety training, including nutrition and lead exposure, was verified before the inspection. Proof of required immunizations for A1 was also verified before the inspection.

LPA discussed the Safe Sleep Regulations with A1 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 A1 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 discussed the requirement to check and log infant napping every 15 minutes for infants under 24 months old. LPA provided a copy of the LIC 9227/Individual Sleeping Plan to be completed for infants under 12 months old.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: DOUGLASS, KATHERYNE & GOMEZ, KAREN	FACILITY NUMBER: 394500999
	VISIT DATE: 01/05/2024

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This facility plans to provide Incidental Medical Services – IMS. For IMS information, see PIN 22-02-CCP. 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) or (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

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 by way of our communication platform. To receive important licensed related information, 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 communications.

A1 was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

A1 was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

A1 understands that licenses are not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. A1 understands that if an unusual incident occurs; Licensing is to be notified via phone call, e-mail or fax within 24 hours and the LIC 624/ Unusual Incident Report shall be submitted within 7 days to remain in compliance. A1 understands that if any structural changes are made to the FCCH; Licensing must be notified PRIOR to construction.

A1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify Licensing and LPA must do an inspection BEFORE children are allowed in said area. A1 understands that children’s and staff’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years. LPA reviewed with A1 the LIC 311D Forms/Records To Keep In Your Family Child Care Homes, Children’s Forms/Records, Facility Forms/Records, and Information to be Posted. A1 understands that fire drills must be conducted and documented once every 6 months.

As of today, 1/5/2024 the facility is approved for a large Family Child Care Home license for a capacity to serve up to either 14 children ( with Landlord consent), two (2) of which must be at least 6 years of age and no more than three (3) may be infants; or 12 children, four (4) of which may be infants. Infants are children under the age of 2.

An exit interview was conducted, and the report was reviewed with A1, Katheryne Douglass.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Stacey Williams
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

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