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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422743
Report Date: 06/30/2023
Date Signed: 06/30/2023 01:31:40 PM

Document Has Been Signed on 06/30/2023 01:31 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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:JORDAN, TARSHAFACILITY NUMBER:
013422743
ADMINISTRATOR:JORDAN, TARSHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 938-1987
CITY:OAKLANDSTATE: CAZIP CODE:
94608
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 7DATE:
06/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tarsha JordanTIME COMPLETED:
01:45 PM
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On 06/30/2023 at 9:00am Licensing Program Analyst (LPA) Christina Uribe, met with licensee Tarsha Jordan for an UNANNOUNCED ANNUAL INSPECTION. Present for the inspection were 7 daycare children and 1 fingerprint cleared assistant (Anna Cai) and 2 residents of home, the licensee's husband (Bryan Oliver) and licensee's adult son (Noah Jordan-Oliver), and the licensee is within ratio today. Upon arrival LPA provided licensee a copy of the Entrance Checklist (LIC 126). The home was toured to conduct a Health and Safety Inspection. The facility currently operates Monday-Friday 7:30am-5:30pm.

Fire Inspector Visit: During today's inspection, Fire Inspector Rolanda Lara of the Oakland Fire Department arrived to conduct a fire clearance inspection at the request of the licensee. The fire clearance is not being granted today.

The home is a single story home with 3 bedrooms, 2 bathrooms, living room, kitchen, dining room, garage and back yard. LPA observed the home to be neat and clean with central heating and ventilation for safety and comfort. The OFF-LIMIT AREAS are the bedrooms, second bathroom, kitchen, garage, and back yard and are inaccessible to children by locked doors, safety gates and visual supervision. The ON-LIMIT AREAS are the living room, dining room, and front bathroom.

All hazardous materials and toxins are kept out of reach from children and are not accessible. The home has a fully charged 2A10BC fire extinguisher, working smoke detector, carbon monoxide detector, telephone and fully stocked first aid kit. There are no pools, hot tubs or any other bodies of water present at the time of the inspection. Per licensee, there are no firearms on the premises or pets in the home.

Page 1 of 4 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE: DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JORDAN, TARSHA
FACILITY NUMBER: 013422743
VISIT DATE: 06/30/2023
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The licensee completed the Health and Safety training, CPR/First Aid certification expires on 09/17/24. The licensee is in compliance with the immunization laws and has completed the mandated reporter training on 06/27/21. Licensee is reminded of their responsibility to renew CPR/First Aid and Mandated Reporter certificates every two years. The licensee conducts and documents fire and disaster drills twice a year and the last conducted drill was on 06/09/23. All required forms are posted and visible for public review.

Records: LPA Uribe reviewed 7 children’s files and personnel records. The facility does have liability insurance which is valid through 03/30/24. Staff interview also conducted and documented.



Provider Information Notices (PINs) & Quarterly Updates: Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders, by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important communication platform. To receive important licensed-related information to licensed facilities, visit the CCLD website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email notifications.

CCLD Inspection Process: 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 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/process.

Criminal Record Clearance: 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.

Page 2 of 4 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JORDAN, TARSHA
FACILITY NUMBER: 013422743
VISIT DATE: 06/30/2023
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Safe Sleep: 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.

Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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/resources/child-care-centers/.

MyChildCarePlan.org: 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.

Megan’s Law: During the exit interview, the licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Unusual Incident/Student Injury Report: Effective August 1, 2003 California Law requires Child Care Licensees to report unusual incidents or injuries to children in care to child’s parents and to the Department of Social Services using the Unusual Incident/Injury Form (LIC 624). Incidents must be reported within 24 hours to the regional office by phone and the written report, LIC 624, within 7 business days.

Page 3 of 4 ***Continued on LIC 809C***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
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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
BAY AREA-CC OAKLAND, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JORDAN, TARSHA
FACILITY NUMBER: 013422743
VISIT DATE: 06/30/2023
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Deficiencies & Advisories found during today's inspection:
  • Type B Violation: 4 of the children's files are have either missing or incomplete Consent for Emergency Medical Treatment (LIC 627) forms.
  • Technical Violation: 2 children's files are in need of an updated immunization records.
  • Technical Violation: The licensee's Mandated Reporter certificate expired 3 days ago, and the licensee will need to renew this certification immediately.
  • Technical Violation: Licensee conducts 15-minute checks on sleeping infants but does not have proper documentation on sleep logs.
  • Technical Violation: Licensee needs to update the Facility Roster (LIC 9040) form.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the licensee, Tarsha Jordan.

Page 4 of 4 ***End of Report***

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: Christina Uribe
LICENSING EVALUATOR SIGNATURE:

DATE: 06/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/30/2023 01:31 PM - It Cannot Be Edited


Created By: Christina Uribe On 06/30/2023 at 12:45 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
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JORDAN, TARSHA
FACILITY NUMBER: 013422743

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

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 as 4 children present today have either an incomplete or missing Consent for Emergency Medical Treatment (LCI 627) forms which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2023
Plan of Correction
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Licensee will ensure that all parents sign and complete these forms and scan a copy of each form and email LPA Uribe at christina.uribe@dss.ca.gov no later than the due date of 07/31/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Chandra Charles
LICENSING EVALUATOR NAME:Christina Uribe
LICENSING EVALUATOR SIGNATURE:
DATE: 06/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2023


LIC809 (FAS) - (06/04)
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