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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500513
Report Date: 09/27/2023
Date Signed: 09/27/2023 11:19:54 AM

Document Has Been Signed on 09/27/2023 11:19 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KOOYMAN, JAMIFACILITY NUMBER:
344500513
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 4DATE:
09/27/2023
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jami KooymanTIME COMPLETED:
11:30 AM
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On 09/27/2023, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit for the purpose of an unannounced case management inspection. Licensee Jami Kooyman (L1) requested an increase in capacity from 8 to 14 children. A fire clearance has been received by LPA and is on file with the Department. LPA arrived at the Family Childcare Home (FCCH) and was met by L1. Also present in the home was an adult Aide. LPA toured the FCCH and observed a census of 2 infants, 1 preschool aged child, and 1 school aged child. LPA accessed Guardian and determined that all required individuals subject to a background review had obtained a criminal record clearance.

A health and safety inspection was conducted in areas accessible to children. The OFF-limits areas include the entire upstairs, master bedroom and bathroom, and garage. L1 understands that OFF-limits areas must remain inaccessible to children in care. LPA discussed ratios for a large capacity, documents required for staff or adult assistants, and LIC 9150 was provided for parents. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for childcare updates, current forms, legislation and regulation information.

In the areas that were evaluated today, no deficiencies were observed at the time of the inspection on 09/27/2023. An exit interview was conducted, and the report was reviewed with L1. LPA provided Licensee Appeal Rights to L1. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Effective today, 9/27/2023, the facility is approved for a large capacity to serve 12 children (when there is an assistant present) with no more than 4 infants OR capacity of 14 children when 1 child is in Kindergarten or Elementary School and 1 child is at least aged 6 years old with a maximum of 3 infants. Infants are children under the age of 24 months old. L1 understands that when there is no assistant present, the facility must reverts back to the ratios of a small capacity.
SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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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