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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455407905
Report Date: 06/25/2021
Date Signed: 06/25/2021 04:35:03 PM

Document Has Been Signed on 06/25/2021 04:35 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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:INTHARASOMBUT, NATECHONNANEE FAMILY CHILD CAREFACILITY NUMBER:
455407905
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
06/25/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:"Natalie" IntharasimbutTIME COMPLETED:
04:45 PM
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A Prelicensing inspection was conducted today by Licensing Program Analyst (LPA), Snow Services will be provided 5am to am - 6 pm, Monday – Friday and off hours overnight. The applicant understands that child care must be provided in the "primary" residence of the applicant. The residence is a 3 bedroom 2 bath home. Applicant was advised that all adults residing or working at the facility must have a criminal background clearance on file with CCLD. All minors residing in the home must be fingerprinted within 30 days of reaching their 18th birthday and obtain a TB clearance. The applicant is aware of the immediate $100 per day civil penalty for adults working or residing in the home without a criminal record clearance.
The following areas are off limits to children: the detached garage is locked and contains the poisons. The detached garage contains poisons and is key locked. The back yard is unfenced and will be used for play; the applicant is aware that constant supervision is required when in the back yard because of hazards at this time. There is a fully fenced front yard for play.
The home appears to be clean and orderly at this time and will remain so during child care hours. There is a working telephone. The sharp knives, cleaning supplies, medicines, are stored out of the reach of children.
The applicant reports there are no weapons in the home and none were observed during the visit.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE: DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2021
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, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: INTHARASOMBUT, NATECHONNANEE FAMILY CHILD CARE
FACILITY NUMBER: 455407905
VISIT DATE: 06/25/2021
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The children in care will have access to age appropriate toys and equipment. The home is equipped with a working carbon monoxide detector, smoke detector and fire extinguisher rated at least 2A10BC. There are no bodies of water on the property and the licensee understands that she must notify the Department prior to adding any.

The applicant understands the responsibility to read and have knowledge of the laws and regulations for operation of a family child care home. Forms and regulations must be obtained from the website. http://ccld.ca.gov/. Megan's Law web site was provided (http://www.meganslaw.ca.gov). Incidental Medical Services (IMS) were discussed with the applicant. 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 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, www.ada.gov/childqanda.htm. The applicant understands that any authorized employee of the Department may enter and inspect the facility with or without advance notice. This report, as well as the AAP Guide to Safe Sleep Practices brochure and new infant sleep regulations, were reviewed and discussed with the applicant. All licensing reports are public information and must be made available upon request for at least three years.

Any proposed changes to the physical plant, telephone number, or change of address shall be immediately reported to the Department.

The physical plant is ready for licensure and all required documents have been submitted. License effective on 6/28/21.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Jaime Snow
LICENSING EVALUATOR SIGNATURE:

DATE: 06/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021
LIC809 (FAS) - (06/04)
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