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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343624842
Report Date: 03/06/2025
Date Signed: 03/06/2025 12:49:26 PM

Document Has Been Signed on 03/06/2025 12:49 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:MOTHERSHED MANAFOV, TIYANNAFACILITY NUMBER:
343624842
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/06/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Tiyanna Mothershed ManafovTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Gagandeep Singh met with licensee, Tiyanna Mothershed Manafov, for an annual inspection. The purpose of the inspection was explained. During inspection, no children were in care.

LPA inspected the day care areas. Day Care Areas: Living room, Dining area, Kitchen, Hallway, One bedroom in hallway, Bathroom in hallway and Backyard. Off limit areas: Master Bedroom, Second bedroom and Garage. There is no pool, spa or any other body of water in the house. During inspection, LPA observed the house is in good repair and free of hazards with proper temperature and ventilation. There is carbon monoxide detector, smoke detector, fully charged fire extinguisher and working telephone available in the house. Cabinets in bathroom have child protective locks installed. There is a variety of age appropriate toys in the house. LPA observed licensee has cribs available for the infants. All the cleaning supplies, poisons and other chemicals are stored inaccessible to the children. Cabinets in kitchen and bathroom have child protective locks installed. All unused electrical outlets have child protective covers installed.

LPA reviewed the facility records. LPA observed licensee has License and other required documents posted in the child care areas. Licensee is aware that fire or emergency drills must be conducted at least once every six month and must be logged. Licensee has a log in place and per log, last drill was conducted on October 05, 2024. Licensee has mandated reporter training completion certificate valid until January 17, 2026.

See next page for continuation ..............

SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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: MOTHERSHED MANAFOV, TIYANNA
FACILITY NUMBER: 343624842
VISIT DATE: 03/06/2025
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed with Licensee the safe sleep regulations and the Child Care Licensing Safe Sleep webpage at


https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/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 Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California. To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.
Exit interview conducted and report was reviewed with the licensee. A notice of site visit was given and must remain posted for 30 days.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Gagandeep Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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