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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500599
Report Date: 11/02/2023
Date Signed: 11/02/2023 04:36:47 PM

Document Has Been Signed on 11/02/2023 04:36 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:KEMOKAI, RASHIDIFACILITY NUMBER:
344500599
ADMINISTRATOR:KEMOKAI, RASHIDIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 513-9610
CITY:ELK GROVESTATE: CAZIP CODE:
95758
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 4DATE:
11/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rashidi KemokaiTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Katy Velasquez and Licensing Program Manager (LPM) Karyn Guerra met with Licensee, Rashidi Kemokai, for the purpose of a case management inspection. A census of 4 infants was observed. The department was made aware of an incident that occurred at the facility in January, 2023 regarding the Licensee in an altercation with another adult. The Licensee did not notify CCLD of the incident. The department also came to learn of an additional adult resident of the home (R1). The Licensee did not report the change in household composition to the department. The department received a police report with a statement that R1 was a resident of the home. Licensee’s address is also listed as the permanent residence of R1 in the Guardian background check system. R1 did not have a criminal record clearance, nor were they associated to the facility. This poses an immediate risk to the health and safety of children in care. Civil penalties were assessed. Licensee stated that R1 lived at the facility on a temporary basis and no longer lives in the home.

Title 22 deficiencies are cited on the subsequent pages of this report. Licensee acknowledges, that FOR TYPE A DEFICIENCIES ONLY upon receipt, licensee shall post LIC 809D with Type A deficiencies for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC 9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the licensee. LIC 9224 and Appeal Rights were provided. Licensee's signature on this report acknowledges receipt of these rights. This report was reviewed with the Licensee. An exit interview was conducted. A Notice of Site visit was posted by LPA and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Karyn Guerra
LICENSING EVALUATOR NAME: Katy Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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Document Has Been Signed on 11/02/2023 04:36 PM - It Cannot Be Edited


Created By: Katy Velazquez On 11/02/2023 at 03:26 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KEMOKAI, RASHIDI
FACILITY NUMBER: 344500599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2023
Section Cited
HSC
1596.885(c):

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Conduct which is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of this state.
CCLD was made aware that the Licensee was involved in an altercation with another adult.
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Licensee received follow up notification from the department. Licensee stated they discussed the incident with the R&R. Licensee shall submit a written UIR to the department by POC due date.
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The Licensee did not report the incident to the department.
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Type A
11/03/2023
Section Cited
CCR102370(d)(1)

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(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility: (1) obtain a California clearance or a criminal record exemption as required by the Department.
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The Licensee stated that R1 was at the facility on a temporary basis and no longer resides at the facility. POC cleared during inspection.
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This requirement was not met, as evidenced by:
CCLD received a police report stating that R1 was a resident of the home. R1 did not have criminal record clearance, nor were they associated to the facility.
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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:Karyn Guerra
LICENSING EVALUATOR NAME:Katy Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/02/2023 04:36 PM - It Cannot Be Edited


Created By: Katy Velazquez On 11/02/2023 at 03:36 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: KEMOKAI, RASHIDI
FACILITY NUMBER: 344500599

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2023
Section Cited
CCR
102416.2(a)(1)

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(a)The licensee shall report the following information the Department by telephone or fax within the Department's next business day and during normal working hours (8am to 5pm). (2) Any change in household composition including adults moving in or out of the home and anyone living in the home
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The Licensee shall submit a written statement aknowledging that she understands that an updated application must be submitted to the department when an additional adult resides in her Family Childcare Home.
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 who reaches his or her 18th birthday. This requirement was not met, as evidenced by: CCLD received a police report stating that R1 was a resident of the home. The Licensee did not report change in household composition to the department.
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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:Karyn Guerra
LICENSING EVALUATOR NAME:Katy Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023


LIC809 (FAS) - (06/04)
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