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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624842
Report Date: 03/23/2023
Date Signed: 03/23/2023 02:51:40 PM

Document Has Been Signed on 03/23/2023 02:51 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:MOTHERSHED MANAFOV, TIYANNAFACILITY NUMBER:
343624842
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
03/23/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tiyanna Mothershed ManafovTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Gagandeep Singh met with applicant, Tiyanna Mothershed Manafov, for a pre-licensing inspection at the facility. Applicant lives in single story home with two minor children. All the adults living in the house has criminal background clearance on file. Applicant has submitted the poof of ownership of the house. Hours of operation will be Monday to Friday 6:00 AM to 8:00 PM. Child care will be provided in areas: Living room, Dining area, Kitchen, Hallway, Bedroom # 1 and Bathroom in the hallway. Off limit areas: Master bedroom, Bedroom # 2, Garage and Backyard. All off limits areas must remain inaccessible to children. Isolation of an ill child will be in the living room. Applicant was notified that prior to use of any off limits area, the department must be notified.

LPA Singh inspected the entire home with the applicant for health and safety hazards. The house has proper temperature and ventilation. All the toxic or dangerous materials are stored in off limit areas. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector. There is first aid kit available. There is a variety of age appropriate toys available. As per the applicant, there are no firearms or weapons in the home. There are two pet cats in the house. All unused electrical outlets are properly covered.

LPA discuss licensing regulations and capacity requirements and a capacity worksheet was provided. Licensing forms and posting requirements were reviewed with the applicant. Applicant has submitted record of all the required immunization, CPR training valid until February 2025 and Mandated reporter training certificate valid until May 2023. Applicant understands that fire/earthquake drills are to be conducted every 6 months and recorded. Applicant understands that baby walkers, bouncers, and excersaucers are not allowed. Smoking is prohibited in family child care homes. Licensee was informed about the Provider Information Notices (PINs) on CCLD website.
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SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: MOTHERSHED MANAFOV, TIYANNA
FACILITY NUMBER: 343624842
VISIT DATE: 03/23/2023
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Applicant is advised all adults, 18 years and older living in the home, helper or assistant must have criminal record clearance and must be associated to the facility by submitting an LIC 9182 with copy of CA DL or CA ID prior to having any contact with children in care. Failure to do so could result in an immediate civil penalty of $100.00 each day.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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)/ (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 applicant is encouraged to frequently visit website at http://www.ccld.ca.gov/ for licensing regulations and new updates. Applicant can also email at childcareadvocatesprogram@dss.ca.gov and ask to be added to the email list for the updates.

During today’s inspection, LPA did not observe any hazard in the day care areas and the house met the requirements for the licensure. Applicant has submitted all of the required documents to the Department. Therefore, as of today, applicant will be approved for a Small family child care home license with maximum capacity of eight.

Copy of this report was reviewed and provided to applicant. This report will be kept in the facility file and will be made available for public review upon request. Desk Duty is available Monday through Friday between 8 AM - 5 PM at (916) 263-5744.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
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