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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 313617082
Report Date: 01/18/2022
Date Signed: 01/18/2022 02:35:19 PM

Document Has Been Signed on 01/18/2022 02:35 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:LAKE, AKIKOFACILITY NUMBER:
313617082
ADMINISTRATOR:LAKE, AKIKOFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 316-1523
CITY:LINCOLNSTATE: CAZIP CODE:
95648
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 9DATE:
01/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Akiko LakeTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Amanda Blesi met with Licensee, Akiko Lake, for the purpose of an unannounced required 1-year inspection. Prior to entry into the home, A COVID-19 risk assessment was conducted with licensee at the door. The licensee's husband and 2 assistants, and adult son were also present during the inspection. All individuals subject to criminal background review have obtained a criminal record clearance. At 1:20p.m. LPA observed a total census of 7 children including 1 infant over 12 months and 1 under 12 months. Two school age children arrived at 1:50pm.
LPA toured the facility, and a health and safety inspection was conducted in all areas accessible to children. Off-limits areas include all bedrooms, laundry room and garage. Licensee acknowledged that children must never enter these areas. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Weapons and ammunition were observed stored and locked separately. LPA did not observe bodies of water on the property. There is a large pond behind the cul de sac. The back yard has a 5 foot wrought iron fence. Toxic and hazardous items are inaccessible to children. Fireplace is barricaded to prevent access by children. Stairs were barricaded to prevent access when children under 5 are present. Outdoor play space is fenced.

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.
AT 1:57pm LPA reviewed children’s files and observed immunization records and emergency contact information. A current roster is being maintained and fire and disaster drills are documented but need to be updated at least once every six months. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current CPR and First Aid certification was verified and expires 1/25/2022, and AB 1207 Mandated Reporter Training was verified for the Licensee and expires 2/2023. (Report continues LIC809-C)
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: LAKE, AKIKO
FACILITY NUMBER: 313617082
VISIT DATE: 01/18/2022
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LPA observed two play yards at the facility. One play yard with a sleeping 5 month old contained a mobile toy and it was discussed with licensee when children are sleeping there shall be no objects inside the crib. Licensee stated she places infant children on their backs when they are napping. LPA reviewed infant sleep plan (LIC 9227) requirement with Licensee, and 15-minute observation checks of napping infants.

LPA discussed the safe sleep regulations with licensee [or facility representative] 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

LPA verified that the annual fees are current. LPA provided the Child Care Advocates Program email address: childcareadvocatesprogram@dss.ca.gov, so the licensee can request to be added to the distribution list to receive Quarterly Updates.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s personnel, and administrative records. For IMS information see Evaluator Manual-Regulation Interpretations and Procedures for Famioy Child Care Homes Section 102417. 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



A technical advisory was provided for a toy that was observed in the play yard of a napping infant under 12 months of age. Appeal Rights given.

Exit interview conducted and report was reviewed with the licensee Akiko
A notice of site visit was given and must remain posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

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
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Amanda Blesi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
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