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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500513
Report Date: 01/07/2025
Date Signed: 01/07/2025 11:25:08 AM

Document Has Been Signed on 01/07/2025 11:25 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/
DIRECTOR:		KOOYMAN, JAMIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 430-7431
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
01/07/2025
TYPE OF VISIT:Case Management - Licensee InitiatedUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Jami KooymanTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 01/07/2025, Licensing Program Analyst Katy Velazquez (LPA) conducted a field visit to the facility for the purpose of a Licensee initiated Case Management inspection to move the master bedroom from off-limits to on-limits, making the master bedroom and bathroom accessible to children in care. LPA arrived at the facility and was met by Licensee Jami Kooyman (L1). LPA disclosed the purpose of the inspection and was granted entrance in to the FCCH. Also present in the FCCH was L1's spouse, and 2 adult residents. LPA toured the facility and observed 5 preschool aged children and 1 infant being supervised by L1 and her spouse. LPA determined through accessing Guardian that all required adults were background cleared and associated to the license.

LPA reviewed the updated facility sketch, to include the master bedroom and bathroom as on-limits, before arrival at the FCHH. LPA ensured that the updated facility sketch is posted in the FCCH. LPA conducted a health and safety inspection in the areas that are accessible to children in-care in the FCCH. LPA also inspected the master bedroom and bathroom. LPA observed child safety locks on the closets and on the cabinets in the master bathroom. LPA reminded L1 to keep chemicals and medications in the cabinets with the child locks. As of today, 01/07/2025, the master bedroom and bathroom will be changed to an on-limits area, and accessible to children in-care. The OFF-limits areas of the FCCH are: entire 2nd floor, laundry room, and garage.

No deficiencies were cited in the areas that were evaluated on 01/07/2024. An exit interview was conducted, and the report was reviewed with Licensee Kooyman. LPA provided L1 with Licensee Appeal Rights. 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: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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