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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293624965
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:40:08 PM

Document Has Been Signed on 06/20/2023 12:40 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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:YOUKHEHPAZ, DOMINIQUEFACILITY NUMBER:
293624965
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/20/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Dominique YoukhehpazTIME COMPLETED:
12:40 PM
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At 10:15 a.m. Licensing Program Analyst (LPA) Matthew Gallo met with applicant Dominique Youkhehpaz for the purpose of a prelicensing inspection. Applicant's husband was also present during the inspection.

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, 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.

Applicant intends to operate 9am-1pm Monday through Friday, and understands that they must be present at least 80% of day care hours. The facility is a 2 bedroom home on roughly 7 acres of land. The home consists of a living room, kitchen, bathroom, bedroom described as a nursery, and master bedroom. There are outbuildings on the property that include a studio, barn, two trailers, and wellhouse. Off-limit areas will include master bedroom and all outbuildings. Applicant understands that children must never enter these off-limit areas.

LPA toured the facility and conducted a full health and safety inspection. LPA observed functioning smoke and carbon monoxide detectors. However, applicant did not have an appropriately sized 2A10-BC fire extinguisher. Cleaning materials, hazardous items, and medications are all stored inaccessible to children. There is a fireplace in the living room that is properly fenced. A firearm is kept in the wellhouse and LPA observed it to be locked properly separately to locked ammunition. There are two swamps on the property, and Applicant has built a fence around outdoor play yard to prevent access to children. The fence is 5 feet tall and features out-swinging fences, but lacks adequate support on the bottom to prevent wire fencing from bending in a way that could allow children to slip underneath. There is also a portion of the fence that lies adjacent to the home's outdoor deck in a way that does not present a 5 foot barrier to an individual standing on the deck.
Report Continues on 809-C.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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 CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: YOUKHEHPAZ, DOMINIQUE
FACILITY NUMBER: 293624965
VISIT DATE: 06/20/2023
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Applicant provided proof of control of property. Applicant understands that until a liability insurance coverage in the amount of $300,000 is provided, the affidavit form LIC282 form will be used. Applicant submitted proof of current CPR/First Aid, completion of Preventative Health and Safety Training, and Mandated Reporter certificate. Applicant understands the CPR and Mandated Reporter training must be renewed every two years.

LPA reviewed Safe Sleep regulations and provided the 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 licensee 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.

Incidental Medical Service (IMS) was discussed. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Family Child Care Homes Sections 102417 and when any IMS is provided, an updated Plan of Operation that includes 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) 513-0301 (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.ht

This facility evaluation report was reviewed and discussed with the applicant. LPA discussed supervision, personal rights, criminal record clearances, ratios and capacity, and maintaining buildings and grounds. Applicant was encouraged to visit the Department's website at WWW.CCLD.CA.GOV for information regarding childcare updates, forms, regulations and legislation pertaining to family childcare homes.

Applicant's license is still pending until the following corrections are made: the fence around the daycare area needs adequate support at the bottom of the fencing, the deck fencing needs to be raised to 5' from the vantage of standing on the deck, and a 2-A10-BC fire extinguisher is needed.

Exit interview conducted and report was reviewed with the applicant, Dominique Youkhehpaz.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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