304202534-7-7-2023-06-CC-AFCN-CTHQ6T-20230707115403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 304202534
Report Date: 06/01/2023
Date Signed: 07/07/2023 11:54:42 AM

Document Has Been Signed on 07/07/2023 11:54 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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	CZAYKOWSKI, KATHERINE		FACILITY NUMBER:	304202534
ADMINISTRATOR:	CZAYKOWSKI, KATHERINE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(714) 538-7731
CITY:	ORANGE	STATE: CA	ZIP CODE:	92867
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS: 11	DATE:	06/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Licensee Katherine Czaykowski		TIME COMPLETED:	01:20 PM

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 06/01/2023, an Annual Random inspection was conducted at the facility by Licensing Program Analyst (LPA) Anna Chan. At 10:45am, LPA met with licensee Katherine Czaykowski and 2 assistants caring for 11 children which included 1 infant and 10 preschool children practicing their dance at the garage. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are 2 adults including the licensee living in the facility. Facility Day care hours are 8am-4pm, Tuesday through Friday. During today’s inspection, LPA and licensee toured the inside and outside areas identified in the facility sketch as accessible to childcare children. The home is a 2-story house. Second floor and other off-limits areas are made inaccessible by means of baby gates and fence. The childcare area includes the living room which is at the right side of the main entrance door upon walking in, passed the living room is the formal dining area and to the left you can access the kitchen. The kitchen has another dining area and passed the dining area is the family room. Upon the entrance door, when you walk towards the left side, there is a door to access the bathroom and garage. Licensee stated the children's primary area is the family room. The home has age-appropriate toys for the ages served such as blocks, puzzles, books, arts and crafts. During today's visit, licensee provided the LPA a copy a new floor plan and a request to add an existing bedroom on the ground floor which will be used for childcare. Page 1 of 4

SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CZAYKOWSKI, KATHERINE	FACILITY NUMBER: 304202534
	VISIT DATE: 06/01/2023

NARRATIVE

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There are working carbon monoxide, smoke detector, and fire extinguishers in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored inaccessible to children. There were no poisons or other items observed which could pose a danger to children. Licensee stated there are no firearms and/or other dangerous weapons in the facility and none were observed during today's inspections. There is a fireplace in the family room screened by a 4-panel glass and screen cover and inaccessible to children in care.

LPA verified there is a working telephone service (cellular service), licensee was reminded that childcare phone needs to remain the in the childcare at all times. Licensee stated they use the backyard for outdoor play. The facility does have bodies of water which is an in-ground pool. LPA inspected and completed the bodies of water checklist.

The licensee does have a current roster of children in care. 5 sample of Children’s records for children present during LPA’s inspection were reviewed. A copy of the emergency information card that contains all the information specified by regulation (LIC 700), Immunization records, Affidavit Regarding Liability Insurance (LIC282), Consent for Emergency Medical Treatment (LIC627), Notification of Parent’s Rights (LIC995A) and found to be in compliance. Licensee stated, there is 1 infant under 24 months enrolled in the childcare. LPA reviewed LIC 9227 Individual Infant Sleeping Plan and napping log for infants.

The licensee and assistant’s Pediatric CPR/First Aid certification expires 02/07/2025. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, a person shall not be employed or volunteer at a family childcare home if he or she has not been immunized against influenza, pertussis, and measles. Proof of immunization against pertussis, measles for licensee and assistants were reviewed and within compliance. The licensee and assistants have a written declaration to decline influenza shot.

Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CZAYKOWSKI, KATHERINE	FACILITY NUMBER: 304202534
	VISIT DATE: 06/01/2023

NARRATIVE

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APPLICANT/LICENSEE KNOWS FACILITY PLANS TO PROVIDE IMS:
This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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

The licensee understands she must be present in the facility and must ensure children in care are always supervised. Children are not to be left alone in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunizations, Pediatric CPR/First Aid, and mandated reporter training. LPA provided Guardian Information and website info: https://www.cdss.ca.gov/inforesources/cdss-programs/community-care-licensing/caregiver-background-check/guardian

CCLD website www.cdss.ca.gov/inforesources/community-care-licensing was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website. A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee.

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-and-resources/safe-sleep as an additional resource. LPA also informed licensee [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.

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

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
ORANGE CO CHILD CARE, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: CZAYKOWSKI, KATHERINE	FACILITY NUMBER: 304202534
	VISIT DATE: 06/01/2023

NARRATIVE

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In the areas that were evaluated, NO deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

Licensee Katherine Czaykowski 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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process.

Exit interview conducted and report was reviewed with the licensee Katherine Czaykowski. A notice of site visit was posted and must remain posted for 30 days.

Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 03/2022) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above.

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SUPERVISORS NAME: Rina Lopez
LICENSING EVALUATOR NAME: Anna Francesca Chan
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC809 (FAS) - (06/04)

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