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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093624569
Report Date: 11/23/2022
Date Signed: 11/28/2022 08:38:48 AM

Document Has Been Signed on 11/28/2022 08:38 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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:NICHELMANN, HALEYFACILITY NUMBER:
093624569
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 1DATE:
11/23/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Haley NichelmannTIME COMPLETED:
03:50 PM
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On November 23rd, 2022 Licensing Program Analyst (LPA) Arianna Manabat met with Applicant Haley Nichelmann for the purpose of an announced pre-licensing inspection. During today’s visit one child was present in the home, the applicant's child. All individuals subject to criminal background review have obtained a criminal record clearance. Applicant plans to operate Monday through Friday from 7:00 AM to 5:30 AM. Applicant plans to watch children ages: Birth to 17.

A health and safety inspection was conducted inside and outside the home. The home is a one-story home and off-limit areas will include: a portion of the backyard area, the laundry room, hallway bathroom, and all closets. Applicant understands that children may never enter these off-limit areas. Toxic and hazardous items are inaccessible to children and out of children’s reach. Sharp knives are stored atop a cabinet . A functioning smoke detector, carbon monoxide detector, and fire extinguisher was observed in the home. LPA observed a weapon which has been locked and stored in the facility and meets regulations.



LPA Manabat observed a spa in the backyard with locked latches and enough support to support the weight of an adult. Spa cover meets Title 22 regulations. LPA discussed all required licensing postings. Applicant has completed the required Preventative Health and Safety course with the Lead Poisoning Prevention training. Current EMSA approved pediatric CPR/First Aid training was verified and kept on file.

Applicant has a completed and up to date Mandated Reporter training and was encouraged to maintain supervision at all times. LPA discussed requirements for staff, adult assistants, and adults living in the home. Type A/B citations and Immediate Civil Penalty regulation deficiencies were reviewed. Applicant understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. Applicant understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to three years. Continued on LIC 812C…………
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2022
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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: NICHELMANN, HALEY
FACILITY NUMBER: 093624569
VISIT DATE: 11/23/2022
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Continued from LIC 812…………….
Applicant understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. LPA reviewed with applicant 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. Applicant 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, 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.

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: http://www.ada.gov/childqanda.htm

LPA discussed the safe sleep regulations with Applicant 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. LPAs also informed Director 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.

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.

Continued on LIC 812 C...............

SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: NICHELMANN, HALEY
FACILITY NUMBER: 093624569
VISIT DATE: 11/23/2022
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A copy of this report was reviewed and provided to applicant. This report will be kept in the facility file and will be made available for public review upon request. The Sacramento Regional Office is available Monday through Friday between 8 AM - 5 PM at (916) 263-5744.

Effective today, 11/23/2022, the facility is licensed for a MAX. CAP: 6 - NO MORE THAN 3 INFANTS OR 4 INFANTS ONLY. CAP 8 - NO MORE THAN 2 INFANTS, 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6. The off-limit areas include a portion of the backyard area, the laundry room, hallway bathroom, and all closets.
SUPERVISORS NAME: Roxana Saravia
LICENSING EVALUATOR NAME: Arianna Manabat
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022
LIC809 (FAS) - (06/04)
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