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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455407905
Report Date: 01/05/2024
Date Signed: 01/05/2024 11:02:40 AM

Document Has Been Signed on 01/05/2024 11:02 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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:INTHARASOMBUT, NATECHONNANEE FAMILY CHILD CAREFACILITY NUMBER:
455407905
ADMINISTRATOR:INTHARASOMBUT, NATECHONNANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 355-9976
CITY:SHASTA LAKESTATE: CAZIP CODE:
96019
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
01/05/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Natechonnanee IntharasombutTIME COMPLETED:
11:12 AM
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On 01/05/2024 at 9:30am, an annual inspection was made to the facility by Licensing Program Analyst (LPA), B.Mendez and T. Dutra. At 10:05am the home was toured inside and outside. The licensee and assistant were supervising 12 children, and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 5:30am - 5:00pm , Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are 2 rooms except and were made inaccessible by baby gate. The children are not using the back yard as the outdoor play area due to weather. There were no pools or other bodies of water observed in the yard.

6 children's records were reviewed at 9:37am. 2 am staff records were reviewed at 9:49am. All adults in the home are cleared.

The following deficiencies was cited: 1 Assistant missing TB test. (see LIC 809D):

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Tammy Dutra
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: INTHARASOMBUT, NATECHONNANEE FAMILY CHILD CARE
FACILITY NUMBER: 455407905
VISIT DATE: 01/05/2024
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To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. 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.

Licensee 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.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed licensee 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 they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Tammy Dutra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
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
CHICO CC RO, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: INTHARASOMBUT, NATECHONNANEE FAMILY CHILD CARE
FACILITY NUMBER: 455407905
VISIT DATE: 01/05/2024
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Incidental Medical Services (IMS) policy was discussed. 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/.

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

During the exit interview, the Licensee Natechonnanee Intharasombut, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Natechonnanee Intaharsombut.
SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Tammy Dutra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/05/2024 11:02 AM - It Cannot Be Edited


Created By: Tammy Dutra On 01/05/2024 at 10:41 AM
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
, 520 COHASSET RD., SUITE 170
CHICO, CA 95926

FACILITY NAME: INTHARASOMBUT, NATECHONNANEE FAMILY CHILD CARE
FACILITY NUMBER: 455407905

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

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: Assistant did not have a TB test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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Licensee to provide documentation to CCLD of Assistant's TB Test.
Documentation due by 01/18/2024.
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:Erin Virrueta
LICENSING EVALUATOR NAME:Tammy Dutra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


LIC809 (FAS) - (06/04)
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