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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500513
Report Date: 11/19/2024
Date Signed: 11/19/2024 03:41:52 PM

Document Has Been Signed on 11/19/2024 03:41 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KOOYMAN, JAMIFACILITY NUMBER:
344500513
ADMINISTRATOR/
DIRECTOR:		KOOYMAN, JAMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 430-7431
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Jami KooymanTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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On 11/19/2024, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the Family Childcare Home (FCCH) for the purpose of an unannounced annual inspection. LPA arrived at the FCCH and was met by Licensee Jami Kooyman (L1). LPA disclosed the purpose of the inspection and was granted entrance into the FCCH. Also present in the FCCH was L1’s spouse, 2 adult children, and 2 minor children. LPA observed 1 infant and 2 preschool aged children being supervised by L1. LPA accessed Guardian to determine that all required adults were background cleared and associated to the license. LPA informed L1 that her adult son did not have a completed background check and that he was not fully cleared. L1 stated that there are no new residents in the home since licensure and confirmed that there are no Registered Sex Offenders living in the facility. LPA completed the RSO profile on 11/08/2024. LPA assessed that annual fees are current.

LPA toured the areas of the FCCH that are accessible to children in-care. L1 accompanied LPA for the entirety of the tour. The OFF-limits areas of the FCCH include the entire upstairs, laundry room, master bedroom and bathroom, and garage. L1 acknowledged that children may never enter these OFF-limits areas. L1 reports her hours of operation to be Monday through Friday from 7:00 am until 5:00 pm. L1 stated that she does not provide overnight or weekend care.

LPA conducted a file review before arrival at the FCCH. LPA provided the Entrance Checklist to L1. LPA discussed the required postings in a FCCH with L1 and ensured that postings are current. LPA reviewed the children’s files for those who were in attendance. LPA reviewed the adult’s files and immunizations. LPA reviewed the Facility’s Roster. LPA reminded L1 to conduct and document Fire Drills at least once every 6 months. A functioning smoke detector and carbon monoxide detector were observed downstairs. L1 stated that cleaners and detergents are stored in the OFF-limits laundry room.

Continued on 809-C

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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Document Has Been Signed on 11/19/2024 03:41 PM - It Cannot Be Edited


Created By: Katy Velazquez On 11/19/2024 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KOOYMAN, JAMI
FACILITY NUMBER: 344500513

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1596.871(c)(1)(A)
Administration of Child Day Care Licensing
Subsequent to initial licensure, a person specified in subdivision (b) who is not exempt from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification, pursuant to subdivision(f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when her adult son was present in the Family Childcare Home without a cleared background check, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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LPA completed an application on Guardian while at the Family Childcare Home. Licensee will contact Guardian and inquire about the clearance by 5 pm on 11/20/2024. Licensee may need to send son for Livescan on 11/20/2024. Licensee will email LPA an update by 5 PM on 11/20/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karyn Guerra
LICENSING EVALUATOR NAME:Katy Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


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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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KOOYMAN, JAMI
FACILITY NUMBER: 344500513
VISIT DATE: 11/19/2024
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LPA observed medications to be stored in kitchen cabinets that are inaccessible to children in-care. LPA observed knives stored in kitchen drawers that have child safety locks. The pellet burning stove in the living room was observed to have a baby-gate barricading the stove. LPA observed a baby-gate barricading the stairway to make the stairs inaccessible to children. LPA observed a 2A10BC fire extinguisher that appeared to have a reading in the green zone. Toys appeared to be safe and in good supply. LPA did not observe an bodies of water on the premises. LPA walked the perimeter of the backyard and ensured the stability of the surrounding fence. L1 stated that unloaded firarm(s) are locked and stored in the OFF-limits area(s) and ammunition is stored in a separate container. L1 stated that she owns 1 cat.

LPA discussed Mandated Reporter Training with L1. Health and Safety Code 1596.8662 requires that all licensed providers, applicants, directors, and employees complete training as specified on their mandated reporter duties and renew their training every 2 years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at http://www.mandatedreporterca.com/. The training is currently provided in English and Spanish. L1 has a current Mandated Reporter Training Certificate which will expire on 10/2025. Current Pediatric CPR and First Aid training was also verified by LPA and will expire on 08/2025.

LPA discussed the Safe Sleep Regulations with L1 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 L1 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 that s/he register all infant devices with the CPSC to be notified of any recalls on purchased equipment.

Incidental Medical Services (IMS) policy was discussed with L1. 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/.

Continued on LIC 809-C

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KOOYMAN, JAMI
FACILITY NUMBER: 344500513
VISIT DATE: 11/19/2024
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Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information through this communication platform. To receive important licensed related information, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

L1 was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

L1 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.

L1 understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours per day per day. L1 understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report/LIC 624 shall be submitted within 7 days to remain in compliance. L1 understands that if any structural changes are made to the FCCH; licensing must be notified PRIOR to construction. L1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in said area. L1 understands that children’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years.



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.

Continued on 809-C

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: KOOYMAN, JAMI
FACILITY NUMBER: 344500513
VISIT DATE: 11/19/2024
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On 11/19/2024, Title 22 deficiencies were cited on subsequent 809-D page(s). LPA informed Licensee Kooyman that this report, dated 11/19/2024, document(s) 1 Type A citation(s) which shall be posted for 30 consecutive days as there is/are immediate risk(s) to the health, safety, or personal rights of children in care. Also, LPA Velazquez informed L1 to provide a copy of this licensing report dated 11/19/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

An exit interview was conducted, and the report was reviewed with Licensee Kooyman. 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.

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
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