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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093616861
Report Date: 07/15/2025
Date Signed: 07/15/2025 11:31:14 AM

Document Has Been Signed on 07/15/2025 11:31 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MARTINEZ, STEVEN/NICHOLS, KODIEFACILITY NUMBER:
093616861
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, S/NICHOLS, K.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 833-5021
CITY:POLLOCK PINESSTATE: CAZIP CODE:
95726
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
07/15/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Kodie Nichols and Steven MartinezTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Soleil Marx and Licensing Program Manager (LPM) Jeevun Birk-Miller met with Licensees, Steven Martinez and Kodie Nichols, for the purpose of conducting an unannounced annual inspection. During the inspection there was a census of eight children in care being supervised by the licensee's. Ages of children were verified during file review to ensure ratio/capacity were adhered to. Facilities hours of operation are Monday through Friday 06:30 AM to 04:30 PM.

A health and safety inspection was conducted in the areas accessible to children. The off-limits areas include: yard other than the fenced off play yard, the entire upstairs, and garage. Licensee understands that children may never enter off-limit areas. LPA observed a working telephone, functioning smoke and carbon monoxide detector, and a fully charged 2A10BC fire extinguisher within the home. LPA observed home was safe, sanitary, and orderly. LPA observed that hazardous items such as detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care, are stored out of children's reach. LPA observed a variety of age-appropriate toys, equipment, and materials available to children within the home. LPA observed supervision and personal rights requirements being followed. LPA observed fireplace and stairs within the home are barricaded to meet regulations. Licensee stated there are no poisons or bodies of water on the premises. Licensee understands that if there are any poisons in the home, all poisons must be locked with a key lock or combination lock. There are firearms on premises which LPA observed to be secured and locked to meet regulation.

LPA reviewed facility, staff, and children's records. LPA observed all required postings were posted and visible to authorized representatives. LPA observed a complete children's roster maintained and a fire drill log with drills being conducted and documented at least every six months. The last fire drill was conducted 05/2025. LPA reviewed records of children’s files and verified all files contained the required licensing forms. LPA reviewed records of Licensee and assistant files and verified both files contained the required licensing forms and documentation. LPA verified Licensee's have approved pediatric CPR/First Aid training, which expires 09/2025 and current Mandated Reporter Training, which expires 03/2027. Licensee understands both CPR and mandated reporter training's’ must be completed every two years.

NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Soleil Marx
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MARTINEZ, STEVEN/NICHOLS, KODIE
FACILITY NUMBER: 093616861
VISIT DATE: 07/15/2025
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LPA observed safe sleep practices were being followed and LPA observed 15 minute sleep checks being conducted and documented for all children under 2 years old. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed 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.

All individuals subject to criminal background review have obtained a criminal record clearance. Licensee was reminded that all adults 18 and over living or working in the home, 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02- CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

During today’s inspection, LPA determined the facility to be in compliance with Title 22 Regulations. No deficiencies were cited in the areas evaluated. During the exit interview, the licensee's confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS. Exit interview conducted and report was reviewed with the licensee's. A notice of site visit was given and must remain posted for 30 days.

NAME OF LICENSING PROGRAM MANAGER: Seychelle De Luca
NAME OF LICENSING PROGRAM ANALYST: Soleil Marx
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC809 (FAS) - (06/04)
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