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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423437
Report Date: 12/14/2022
Date Signed: 12/14/2022 05:28:28 PM

Document Has Been Signed on 12/14/2022 05:28 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME:BROOM-JACKSON, LORI & BROOM, GERALDEANFACILITY NUMBER:
013423437
ADMINISTRATOR:BROOM-JACKSON, LORIFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 501-8776
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: DATE:
12/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Lori Broom-Jackson and Geraldean BroomTIME COMPLETED:
05:30 PM
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On December 14th, 2022 @ 2:40pm, Licensing Program Analyst (LPA) April Wright met with licensees Lori Broom-Jackson and Geraldean Broom for an Unannounced Required 1 Year Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensees. Present during inspection were Seven (7) children (1 infant, 3 preschool and 3 school age children) and fingerprint cleared assistants Doretha Jernigan and Sarah Flewellen LPA toured the facility to conduct a health and safety inspection. Hours of operation are 8:00am - 4:00pm Monday through Friday.

The 2 story home was clean and orderly, with heating and ventilation for safety and comfort of children in care. The home consists of the living room, family room, dining area, kitchen, pantry, one bedroom, one and a half bathrooms and garage. The second floor consists of three bedrooms, three bathrooms, loft, and laundry room. The isolation area is the front room which is a section away from other children in care.

On limit areas include: First level: Living/Dining room area (Daycare), family room, half bathroom and portion of the backyard.
Off-limits areas include: First level: Bedroom and full bathroom, Entire second level of home, Side portion of back yard and garage.

The off limits are and will be made inaccessible by closed and/or locked doors and visual supervision. There is a gate at the bottom of the stairs to prevent access to the upper level of the home. There are no pools, hot tubs or any other bodies of water present in the on-limit areas during today’s inspection. LPA did not observe any hazardous materials or toxins accessible to children during today's inspection. There are ample age appropriate toys that appear to be safe and in good condition.

The home has a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detector, fully stock First Aid Kit. and telephone. There is a fireplace that is locked and inaccessible to children in care. Per licensee there are no firearms in the home. The licensee is in compliance with the immunization laws which pertains to all childcare providers.

See LIC809 -C for continuance
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2022
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: BROOM-JACKSON, LORI & BROOM, GERALDEAN
FACILITY NUMBER: 013423437
VISIT DATE: 12/14/2022
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LPA requested and reviewed the files of seven (7) children in care. The children's files contained, Parents rights, medical consent forms and identification and emergency contacts. The facility roster was review and copies were obtained. The licensee conducts fire and disaster drills twice a year and the last was conducted on 11/16/2022. The licensee has a current CPR/First aid certificate which expires on 6/2023 and Mandated Reporter was completed on 5/8/2022. The licensee is in ratio today. All required forms are posted and visible for public review.

Incidental Medical Services (IMS) policy was discussed. NO IMS PROVIDED AT THIS FACILITY. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Child Care Centers Sections 101173 and 101226. 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/childqanda.htm

California Law requires Child Care Centers 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 by phone, fax, or electronic mail. Roster of the children must be properly maintained, and fire/disaster drill every six months must be documented.

The licensee is reminded any structural changes to the home or additions to the childcare facility must be reported to Community Care Licensing. LPA discussed the Safe sleep regulations with licensee and discussed Child Care Licensing Safe Sleep webpage 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.

See LIC809C for continuance.

SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: BROOM-JACKSON, LORI & BROOM, GERALDEAN
FACILITY NUMBER: 013423437
VISIT DATE: 12/14/2022
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Licensee was reminded that all adults 18 and over, 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 childcare center. 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.

There are no deficiencies cited. A notice of site visit was given and must remain posted 30 days. Exit interview conducted and report was reviewed with Licensee Lori Broom-Jackson
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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