Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293605639
Report Date: 05/23/2018
Date Signed 05/23/2018 01:48:51 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: 9DATE:
05/23/2018
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tulum, DotheeTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA's) Keven Peters & Chris Bello met with licensee for an annual/random inspection and toured areas of the home accessible to the children. Off-limit areas: kitchen, garage, cabana. Licensee acknowledged that children may never enter these off-limit areas. Licensee stated there are no new residents in the home, and all adult residents have criminal record clearances. Today’s census was 9 preschool age children with the licensee and assistants.

LPA observed current CPR/First Aid certificate (exp: 09/2019), posted License, Parents' Rights Poster, facility sketches, and Emergency Disaster Plan. LPA discussed recent changes in licensing requirements, including SB 277 and SB 792 pertaining to immunization requirements for children and staff, also discussed today was AB1207 Mandated Reporter training. LPA reviewed children's records and client roster. Licensee provided proof of immunization's for herself and her assistant.

LPA observed care and supervision of children in care. LPA observed hazardous items (detergents, cleaning compounds, medication, sharp utensils, and other items that could pose a danger to children in care). properly stored out of children's reach. There is a working telephone in the home.
Licensee stated there are no weapons in the home. Fire extinguisher, carbon monoxide and smoke detector meet regulation. LPA observed fire drills documented on a calendar. Toys appear to be safe and in working order. The backyard is fenced, and LPA’s observed a drained swimming pool, the pool was properly fenced with a fence at least five ft high, with a self-latching gate that swings away from the pool.
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2018
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
VISIT DATE: 05/23/2018
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LPA provided the Licensing Agency website (www.ccld.ca.gov), so the licensee may obtain updated licensing information, regulations, and forms.

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

No deficiencies were issued during today’s visits.



Report was reviewed with licensee, exit interview conducted
SUPERVISOR'S NAME: Jennifer BrekkeTELEPHONE: (916) 263-5717
LICENSING EVALUATOR NAME: Keven PetersTELEPHONE: (916) 216-7796
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2018
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2018
LIC809 (FAS) - (06/04)
Page: 2 of 2