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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 455407905
Report Date: 01/22/2025
Date Signed: 01/22/2025 03:16:16 PM

Document Has Been Signed on 01/22/2025 03:16 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
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:INTHARASOMBUT, NATECHONNANEE FAMILY CHILD CAREFACILITY NUMBER:
455407905
ADMINISTRATOR/
DIRECTOR:		INTHARASOMBUT, NATECHONNANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 355-9976
CITY:SHASTA LAKESTATE: CAZIP CODE:
96019
CAPACITY: 14TOTAL ENROLLED CHILDREN: 18CENSUS: 8DATE:
01/22/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Licensee IntharasombutTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 01/22/2025 at 1:00pm, an annual inspection was made to the facility by Licensing Program Analyst (LPA), Nicolette Cunningham. At 1:15pm the home was toured inside and outside. The licensee and assistant were supervising eight children, and operating within the licensed capacity and ratio requirements. The facility’s operating hours are 5:00am - 7:00pm, Monday–Friday. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are 2 rooms and were made inaccessible by baby gate. The children use the back yard as the outdoor play area which is fully fenced. There were no pools or other bodies of water observed in the yard.

Six children's records were reviewed at 1:30pm. Three staff records were reviewed at 2:00pm. All adults in the home are cleared.

The following deficiencies were cited: no consent for medical treatment for one child, two swing sets not anchored down, no immunization records for one staff, children did not have access to the bathroom, sleep checks were not logged (see LIC 809D).

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: INTHARASOMBUT, NATECHONNANEE FAMILY CHILD CARE
FACILITY NUMBER: 455407905
VISIT DATE: 01/22/2025
NARRATIVE
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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.

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/.

SUPERVISORS NAME: Erin Virrueta
LICENSING EVALUATOR NAME: Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
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-DAY CARE, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME: INTHARASOMBUT, NATECHONNANEE FAMILY CHILD CARE
FACILITY NUMBER: 455407905
VISIT DATE: 01/22/2025
NARRATIVE
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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: Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2025
LIC809 (FAS) - (06/04)
Page: 8 of 8
Document is an Amendment of Original Document on 02/10/2025 03:11 PM


Created By: Nicolette Cunningham On 01/22/2025 at 02:40 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
CHICO-DAY CARE, 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: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 01/22/2025 03:16 PM - It Cannot Be Edited


Created By: Nicolette Cunningham On 01/22/2025 at 02:40 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
, 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: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

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 in that no fire drill was documented within the last six months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Licensee stated she will conduct and document a fire drill and send proof to LPA Cunningham.

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:Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 01/22/2025 03:16 PM - It Cannot Be Edited


Created By: Nicolette Cunningham On 01/22/2025 at 02:40 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
, 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: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

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 in sleep checks were not documented which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Licensee stated sleep checks will be documented and she will send proof to LPA Cunningham.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

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 in one child's file did not contain immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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The licensee obtained records and provided at approximately 2:30pm. Citation cleared.
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:Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 01/22/2025 03:16 PM - It Cannot Be Edited


Created By: Nicolette Cunningham On 01/22/2025 at 02:40 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
, 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: 01/22/2025

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 in one out of three files did not contain immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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The licensee stated she will obtain records and send proof to LPA Cunningham.
Type B
Section Cited
CCR
102418(a)
Immunizations
(a) Prior to admission to a family day care home, children shall be immunized against diseases as required by the California Code of Regulations, Title 17, beginning with Section 6000.

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 in one out of six children did not have proof of immunization records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/29/2025
Plan of Correction
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Licensee provided at approximately 2:20pm. Citation cleared.
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:Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 01/22/2025 03:16 PM - It Cannot Be Edited


Created By: Nicolette Cunningham On 01/22/2025 at 02:40 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
, 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: 01/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102423(a)
Personal Rights
(a) Each child receiving services from a family child care home shall have certain rights that shall not be waived or abridged by the licensee regardless of consent or authorization from the child's authorized representative. These rights include, but are not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in one out of one bathroom was not accessible to children in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/23/2025
Plan of Correction
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2
3
4
The licensee stated she will ensure the bathroom is accessible to children at all times.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Nicolette Cunningham
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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