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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422933
Report Date: 06/17/2021
Date Signed: 06/17/2021 01:16:40 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/17/2021 01:16 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:KIKON, JULIEFACILITY NUMBER:
013422933
ADMINISTRATOR:JULIE KIKONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 969-5053
CITY:SAN LEANDROSTATE: CAZIP CODE:
94579
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 11DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Julie KikonTIME COMPLETED:
01:00 PM
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On 06/17/2021, Licensing Program Analyst Jabari Wilson met with licensee Julie Kikon for an UNANNOUNCED INSPECTION. Present for this visit was licensees fingerprint clear assistants, Mhalo Kikon and Theresa Mesa, and 11 children in care. The home was toured to conduct a Health and Safety Inspection.

This is a one story home that consists of a living room, dining room, 3 master bedrooms/bathrooms, a hallway bathroom, garage, and a laundry room. The home appears to be neat and clean with heating and ventilation for safety and comfort. The OFF-LIMIT AREAS are the master bedroom located on the left side of the home, the two master bathrooms located inside the on limit bedrooms, the laundry room, and the garage which will be inaccessible by closed and/or locked doors and visual supervision. The ON-LIMIT AREAS are the dining room (library), kitchen, living room, master bedroom located near the kitchen, and the hallway bathroom. The ISOLATION AREA will be the master bedroom located on the right side of the home. Outdoor play area will be completely fenced. The outdoor play area appears to be free from defects or dangerous conditions. There are ample age appropriate toys that are safe and appeared to be clean. There are no pools, hot tubs or any other bodies of water on the premises. All hazardous materials and toxins are kept out of the reach of children and it was observed that there are no toxins or hazardous items accessible today.

The home has a fully charged 3A40BC fire extinguisher, working smoke detector, working carbon monoxide detector, working telephone, and fully stocked First Aid Kit. The licensee’s Health and Safety training is completed and CPR and First Aid certificate has expired 04/20/2021. The licensee is in compliance with new immunization law which pertains to day care providers. There are no wall heaters or fireplaces in the home. The licensee's mandated reporter training has expired on on 06/05/18. Per licensee, there are no firearms in the home. A copy of the lease was reviewed and shows control of property.

SEE 809-C FOR CONTINUANCE
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jabari Wilson
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: KIKON, JULIE
FACILITY NUMBER: 013422933
VISIT DATE: 06/17/2021
NARRATIVE
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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

The licensee is aware the safe Sleep Regulations can be found in Title 22, Division 12, Chapter 1, Section 102425.

The licensee is reminded any structural changes to the home or additions to the child care facility must be reported to Community Care Licensing. Also, any adults moving into the home must be reported to Community Care Licensing prior to them moving in and all requirements must be met before the person lives in the facility. Licensee was reminded of Departments inspection authority without any notice.

Effective August 1, 2003 California Law requires Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. Children's roster must be properly maintained, and fire/disaster drill every six months must be documented.

The licensee was also reminded that baby bouncers, saucers, johnny jumpers and similar items are not allowed in licensed day care.

For licensing updates email childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list

See 809-D for deficiencies cited today. Appeal rights provided and discussed. A notice of site visit was given and shall remain posted for 30 days. Exit interview conducted.
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Jabari Wilson
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2021 01:16 PM - It Cannot Be Edited


Created By: Jabari Wilson On 06/17/2021 at 12:17 PM
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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: KIKON, JULIE
FACILITY NUMBER: 013422933

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2021
Section Cited
CCR
102416(c)

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Personnel Requirements. The Licensee and other personnel as specified shall complete training on preventive health practices including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.
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The Licensee will submit proof of enrollment for herself, Mhalo Kikon and Theresa Mesa in an approved CPR/First Aid course, to LPA by email, fax or mail by 07/17/2021.

The Licensee will submit a copy of the CPR/First Aid certificate upon completion of the class.
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This requirement was not met as evidenced by:
Based on file review and and visually observing expired CPR/First Aid certificates, licensee as well as her assistants, being alone with children in care and not having a current CPR/First Aid certificate poses a potential health and safety risk to children care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.

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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:Jason Jang
LICENSING EVALUATOR NAME:Jabari Wilson
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2021


LIC809 (FAS) - (06/04)
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