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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343623370
Report Date: 11/08/2021
Date Signed: 11/08/2021 01:27:13 PM

Document Has Been Signed on 11/08/2021 01:27 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:KILMER, ADRIANNAFACILITY NUMBER:
343623370
ADMINISTRATOR:KILMER, ADRIANNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 228-1489
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
11/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Adrianna KilmerTIME COMPLETED:
01:45 PM
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On Monday, 11/08/21, Licensing Program Analyst (LPA) Jan Hoshida conducted an unannounced random annual inspection and met with Licensee Adrianna Kilmer. LPA observed there were three day care children present in the facility during this inspection with Licensee and Licensee's Assistant. The off-limit areas include master bedroom, son's room, garage, and side yard. Licensee requested to put the bedroom #3, back bathroom, and living room off-limits and requested to put her master bedroom and side yard on-limits during the inspection. Licensee acknowledged that children may never enter these off-limit areas. LPA inspected the master bedroom and side yard and it is approved for day care use as of today. Licensee stated there are no new residents in the home since licensure. All adult residents have criminal record clearances. The hours of operation are Monday through Thursday from 8:00am to 5:00pm and Friday from 8:00am to 4:30pm.

LPA conducted a health and safety inspection inside and outside of the home. LPA observed that there were no hazardous items accessible to children. LPA observed there the fireplace is barricaded in the home. LPA observed that cleaning materials were inaccessible. Fire extinguisher, smoke detector, and carbon monoxide detector meet regulation. LPA observed current Mandated Reporter Training in file. LPA observed current CPR/1st training on file that will expire on 7/10/23. LPA discussed current COVID guidelines with Licensee. LPA checked facilities fees and confirmed that it is up to date. LPA observed that the weapons in the home were locked and will conduct a continuation inspection to further inspect Licensee's weapons in the home. LPA reviewed children's files, sleep logs for children under two years of age, and file for Licensee's assistant.

REPORT CONTINUED ON NEXT PAGE

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Jan Hoshida
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2021
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: KILMER, ADRIANNA
FACILITY NUMBER: 343623370
VISIT DATE: 11/08/2021
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.


This facility does not currently provide Incidental Medical Services- IMS. 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.

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-and-resources/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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email to [email protected]. 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/process.

No Title 22 Deficiencies observed in the areas that were evaluated. LPA reviewed report with the Licensee and provided copies along with Appeal Rights. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Adrianna Kilmer.

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Jan Hoshida
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2021
LIC809 (FAS) - (06/04)
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