Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293605639
Report Date: 10/31/2016
Date Signed 10/31/2016 03:07:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:DOTHEE, TULUMFACILITY NUMBER:
293605639
ADMINISTRATOR:DOTHEE, TULUMFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(530) 271-1258
CITY:ROUGH & READYSTATE: CAZIP CODE:
95975
CAPACITY:14CENSUS: 5DATE:
10/31/2016
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Tulum DotheeTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Amie Randa met with licensee Tulum Dothee for an unannounced annual inspection. The facility operations Monday-Thursday from 8:45am-5:15pm and Friday 8:45am-:2:30pm. Simmer hours are Monday-Friday 8:00am-5:30pm. LPA toured all areas of the home that are accessible to the children and observed care and supervision, a current roster of children, capacity and ratio. Today’s census was five preschool aged children. Also present in the home was the licensee's assistant and husband who has been fingerprint cleared. LPA confirmed that all adult residents residing or working in the home have criminal record clearances. LPA advised licensee if anyone over the age of 18 years old moves into the home they must have a criminal record clearance as well. LPA observed posting of the license, Parent's Rights and the current disaster plan.

Off-limit areas include the garage and the pool house. Licensee acknowledged that children may never enter these off-limit areas. The backyard is fenced and licensee acknowledges that children may never be left unsupervised in an unfenced area of the yard. LPA observed an in ground pool in the back yard that is surrounded by 5 foot wrought iron fencing, the pool gate swings away from the poll and is self latching/closing; therefore the pool fencing meets the regulations. LPA also observed a spa in the background that has a tight fitting lid that has four latches on each side; the latched were latched in place; however they were not locked which is an immediate risk to children in care. Licensee stated there are no weapons in the home.

LPA observed current CPR and First Aid certificates that expires on 09/2017. LPA observed that poisons are locked and that fire extinguisher, smoke detector and carbon monoxide detector meets regulation. Cleaning materials, hazardous items and medications are all inaccessible to children. LPA observed a Fire Drill Log and the licensee is conducting fire drills at least every six months. There is a working telephone, toys appear to be in a safe condition and the home appears to be clean and orderly.
Report continued on 809 C
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2016
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: DOTHEE, TULUM
FACILITY NUMBER: 293605639
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2016
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2016
Section Cited
102417(g)(5)
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Operation of a Family Child Care Home. All pools, spas, hot tubs, fish ponds, or similar bodies of water shall be covered or fenced as specified to be inaccessible to children. LPA observed a spa that has a tight fitting lid that has four latches on each side; the latched were latched in place; however the latches
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POC: Licensee immediately order a hot tub spa cover lock key on amazon.com, she stated the children will not enter the back yard until the key arrives in the mail and the latches are locked. LPA will make a return visit to verify the latches are locked.
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were not locked which is an immediate risk to children in care.
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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: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2016
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: DOTHEE, TULUM
FACILITY NUMBER: 293605639
VISIT DATE: 10/31/2016
NARRATIVE
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LPA provided the Community Care Licensing’s website (www.ccld.ca.gov), so the licensee can obtain updated licensing information, new regulations and access forms.

LPA discussed the new Immunization Regulations (SB 277 and SB 792), new smoking regulation (AB 1819-Smoking Prohibition) and the new Incidental Medical Services (IMS) policies with the licensee. Incidental Medical Services (IMS) policy was discussed. 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 (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: http://www.ada.gov/childqanda.htm


Title 22 Deficiencies have been cited on the attached LIC 809 D. Upon receipt of Type A citations, licensee shall post and provide copies of the LIC 809 D for parents/guardians of children in care and for parents/guardians of newly enrolled children for the next 12 months. Licensee must also keep the signed LIC 9224, acknowledging receipt of LIC 809 D in each child's file.

LPA read the report to the licensee and she acknowledged that she understands today's inspection.. Appeal Rights provided and Notice of Site Visit posted..
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Amie RandaTELEPHONE: (916) 208-2538
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2016
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2016
LIC809 (FAS) - (06/04)
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