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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293624965
Report Date: 07/18/2023
Date Signed: 07/18/2023 10:43:42 AM

Document Has Been Signed on 07/18/2023 10:43 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:YOUKHEHPAZ, DOMINIQUEFACILITY NUMBER:
293624965
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
07/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Dominique YoukhehpazTIME COMPLETED:
10:55 AM
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At 9:05 a.m. Licensing Program Analyst (LPA) Matthew Gallo met with applicant Dominique Youkhehpaz for the purpose of a prelicensing visit to ensure corrections determined necessary during the first prelicensing visit on 6/20/2023 were made. Applicant's husband was also present during the inspection.

On 6/20/2023, LPA conducted a prelicensing visit and observed that the following corrections were necessary prior to licensing: 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.

LPA observed that all necessary corrections had been made. In addition, LPA conducted a health and safety inspection of the facility. Cleaning materials, hazardous items, and medications are all stored inaccessible to children. LPA observed functioning smoke and carbon monoxide detectors. There is a fireplace in the living room that is properly fenced. Outdoor deck stairs are properly barricaded. A firearm is kept in the wellhouse and LPA observed it and ammunition locked separately according to regulations. There are two swamps on the property, which now have a fence that meets all regulations in preventing access to children.

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.


Report Continues on 809-C.
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Matthew Gallo
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023
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: 07/18/2023
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Effective today, July 18, 2023, the facility is approved for a Small Family Child Care Home license for a capacity of 6 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.

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

DATE: 07/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2023
LIC809 (FAS) - (06/04)
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