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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500513
Report Date: 12/08/2021
Date Signed: 12/08/2021 01:49:59 PM

Document Has Been Signed on 12/08/2021 01:49 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:KOOYMAN, JAMIFACILITY NUMBER:
344500513
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/08/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jami KooymanTIME COMPLETED:
02:00 PM
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On 12/08/21 at 10:00am, Licensing Program Analyst (LPA) Aruna Sridharan met with applicant Jami Kooyman. LPA informed the purpose of the inspection; applicant is requesting a small family home child care license. LPA toured the two storey single family home with four bedrooms and three bathrooms. All adults have a criminal record clearance. The facility will operate Monday-Friday 7:00 am-6:00 pm.

A health and safety inspection was conducted inside and out. The home has master bedroom/bath, one bathroom, a living room, dinning area, kitchen, laundry and garage downstairs and three bedrooms and one bathroom upstairs. The off-limits areas in the home will be entire upstairs, master bedroom/bath, laundry and garage. Off-limit areas will remain inaccessible to children by gates and/or supervision and understands that children may never enter these off-limit areas. The applicant stated there are weapons in the home and LPA observed that the firearms and ammunition meet Title 22 regulations.

There is fireplace in the living area which is barricaded. The 2A-10-B-C fire extinguisher is wall mounted in the living room which is inaccessible to children. LPA tested and ensured that the smoke alarm and Carbon Monoxide meet regulations. First aid kit and emergency kit is in the hallway closet and medications are in the upper cabinet in the kitchen. Toxins and hazardous items are inaccessible to children. Cleaning supplies are kept in the laundry room.

Applicant rents the home and LPA observed the lease. Applicant will use the affidavit for the liability insurance. Applicant has completed the 8-hours Preventative health training with the Lead Poison Prevention module on 11/18/2021 and CPR/First Aid that expires on 08/2023. Applicant has completed the required AB1207 Mandated Reporter training that expires on 10/2023. Applicant understands that the training must be completed once every two years.
Report continues on 809C.....
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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: KOOYMAN, JAMI
FACILITY NUMBER: 344500513
VISIT DATE: 12/08/2021
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LPA reviewed forms required for children's records, including immunization cards, and Safe Sleep Regulations PIN. Applicant stated that Safe Sleep Practices and Regulations are understood. She stated she understand infants cannot sleep in car seats, swings or other items not intended for sleeping. LPA advised applicant that baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes (FCCH).
Applicant understands that children’s records are to be maintained according to Title 22 regulations, and be accessible to licensing for up to three years. Applicant understands that her License, Emergency Disaster Plan, Earthquake Preparedness Checklist and the Parents Rights Poster must be posted in the home. Applicant has posted the required documents. Records, postings and reporting requirements were discussed. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.

Applicant plans on providing transportation. LPA shared the car seat law and that all legal requirements to drive should be met along with childcare requirements of CPR/First aid and Mandated Reporter certifications. Applicant understands that a current roster must be maintained and it was understood that fire drills (by checking fire extinguisher and smoke detector) will be conducted and documented at least every six months.

LPA explained the Inspection Authority, Zero Tolerance and Immediate Civil Penalty regulation, deficiencies and citations with the applicant. LPA explained Unusual Incident Reporting requirements to notify the department within 24 hours of an incident and the requirement to follow up with the written report LIC 624 within seven days.

LPA discussed the Immunization Regulations SB 792, the requirement that all individuals working or volunteering at a licensed Family Child Care Home(FCCH) must have vaccinations against, Pertussis, Measles and Influenza. Proof of required vaccines have been obtained from applicant. The applicant takes Flu shot every year.

Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that if anyone else works with the children, they must also obtain the following: EMSA approved or American Red Cross or American Heart Association CPR and first aid training, immunization for TB, Measles, Pertussis and Influenza, and complete AB1207 Mandated Reporter Training.
Report continues on 809C......
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: KOOYMAN, JAMI
FACILITY NUMBER: 344500513
VISIT DATE: 12/08/2021
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Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if she wants to make any off-limit areas an ON-limits for children, she must notify licensing and LPA must do an inspection BEFORE children are allowed in the areas.

Applicant understands that her FCCH license is not transferable, and once licensed, applicant must live in the home and be present for 80% of the operating hours. Applicant understands children must have 100% supervision in unfenced areas. LPA explained to applicant that if she moves and wants to continue to provide care, she must submit a change of location application and have the new home inspected again before providing care.

The applicant does not plan on providing IMS care. 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

LPA provided COVID-19 resources and updated regarding the CDC and state guidelines in following the Covid pandemic safety precautions while providing care for children. LPA also discussed the Self Assessment checklist with licensee.

As of 12/08/2021 the facility is approved for a Small Family Child Care Home licensed to serve a maximum capacity of six children with no more than three infants or four infants only or a capacity of eight children with no more than two infants, one child must be in Transitional Kindergarten/Elementary School and one child must be at least six years old. The licensee's children under the age of 10 will count in the ratios.
SUPERVISORS NAME: Justin L Denton
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
LIC809 (FAS) - (06/04)
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