<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 093626492
Report Date: 12/12/2024
Date Signed: 12/12/2024 09:58:16 AM

Document Has Been Signed on 12/12/2024 09:58 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:NICHELMANN, HALEYFACILITY NUMBER:
093626492
ADMINISTRATOR/
DIRECTOR:
NICHELMANN, HALEYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 893-3578
CITY:PLACERVILLESTATE: CAZIP CODE:
95667
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 2DATE:
12/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Haley NichelmannTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
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 December 12th, 2024, Licensing Program Analyst (LPA) Soleil Marx met with Licensee, Haley Nichelmann, for the purpose of an announced pre-licensing change of location inspection from previous license # 093624569. During the inspection, Licensee's spouse and two minor children were present. All individuals subject to criminal background review have obtained a criminal record clearance. Hours of operation: Monday through Friday from 7:00 AM to 5:30 PM.

The home is a single story 3 bedroom 2 bath home. Off-limits areas include: laundry room, master bathroom, master bedroom closet, RV access side yard, and rear fenced off section of backyard, sheds. Licensee understands children may never enter off-limit areas. Off-limit areas are made inaccessible by shut doors, locked doors, child locks, and supervision.

Fire clearance was granted on 12/10/2024 by Diamond Springs-El Dorado Fire Protection District for a capacity of 14 children.

Licensee provided proof of control of property. Because the licensee rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The licensee obtained a signed Property Owner/Landlord Consent form (LIC 9149).

A health and safety inspection was conducted on the interior and exterior of the home. Toxic and hazardous items, sharp knives, and medications are inaccessible to children. LPA observed a functioning smoke detector, carbon monoxide detector, and a fully charged 2A10BC fire extinguisher within the home. LPA observed fireplace is properly barricaded to meet regulation. entire front/back yard is fenced. Licensee stated that there are no poisons in the home. LPA advised the applicant that if there are ever any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA observed firearms and ammunition within the home are stored and locked to meet regulatory requirements. Licensee stated there are no bodies of water on the premises.

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Soleil Marx
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: NICHELMANN, HALEY
FACILITY NUMBER: 093626492
VISIT DATE: 12/12/2024
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
26
27
28
29
30
31
32
Licensee has current EMSA approved pediatric CPR/First Aid trainings which expires 01/2025. Licensee/applicant has current Mandated Reporter Training which expires 08/2026. Licensee was reminded that both CPR and mandated reporter training's’ must be completed every two years.

LPA reviewed with licensee the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, postings, capacity, supervision, reporting requirements, type A/B citations, open door policy, personal rights, firearm regulations.

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.

Licensee 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.

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) 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.

Licensee was informed of the MyChildCarePlan.org site, 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.

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Soleil Marx
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: NICHELMANN, HALEY
FACILITY NUMBER: 093626492
VISIT DATE: 12/12/2024
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
26
27
28
29
30
31
32
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 platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication

Effective, 12/16/2024, the facility is approved for a large capacity to serve 12 children (when there is an assistant present) with no more than 4 infants or capacity of 14 children when 1 child in tk/kindergarten or elementary school and 1 child at least age 6 and a maximum of 3 infants. Infants are children under the age of two years.

Licensee understands that when there is no assistant present, the facility reverts to the ratio of a small capacity.

Exit interview conducted and report was reviewed with the applicant, Haley Nichelmann. A notice of site visit was given to licensee and must remain posted for 30 days.

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Soleil Marx
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3