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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423437
Report Date: 02/29/2024
Date Signed: 02/29/2024 04:39:08 PM

Document Has Been Signed on 02/29/2024 04:39 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: 3DATE:
02/29/2024
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Lori Broom-JacksonTIME COMPLETED:
04:45 PM
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On February 29th, 2024 at approximately 2:25pm, Licensing Program Analyst (LPA) April Wright met with licensees Lori Broom-Jackson for an Unannounced Required 3 Year Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. Present during inspection were three (3) children ( 1 infants / 2 preschool age) and fingerprint cleared assistant Doretha Jernigan. LPA toured the home to conduct a health and safety inspection. Hours of operation are 8:00am - 4:00pm Monday through Friday.

The two story home consists of the living room, family room, dining area, kitchen, pantry, four bedrooms, three and one half bathrooms, loft, laundry room and garage. The home was neat and orderly, with heating and ventilation for safety and comfort of children in care. The isolation area is the Front room or section of the living room which is a section away from other children in care.

On limit areas include: First floor: Living/Dining room area (Daycare area), family room, half bathroom (to right of entry to home) and portion of the backyard(fenced/gated). Backyard is not in use during winter months due to rain/flooding risks. Licensee uses park down the street from the home for outside when weather permits.
Off-limits areas include: Second floor: Remaining three bedrooms and three bathrooms, Side portion of back yard, loft, laundry room and garage.

The off limits area 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 home. LPA did not observe any hazardous materials, cleaning products or toxins accessible to children during today's inspection. The home has a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detector, fully stock First Aid Kit. and telephone. See LIC809C for continuance
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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: 02/29/2024
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There is a fireplace that is locked with screen gate and inaccessible to children in care. Per licensee there are no firearms, weapons or pets in the home. The licensee is in compliance with the immunization laws which pertains to all childcare providers.

LPA requested and reviewed the files of three (3) children in care. The children's files contained, Parents rights, medical consent forms and identification and emergency contacts. The facility roster was reviewed and copies were obtained. The licensee conducts fire and disaster drills twice a year and the last was conducted on 2/8/2024. The licensees and assistants have a current CPR/First aid certificate which expires on 8/2025 and Mandated Reporter was completed on 5/8/2022 and 6/2/2022. The licensee is in ratio today. All required forms are posted and visible for public review.

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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP . 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: https://www.ada.gov/resources/child-care-centers/.

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-andresources/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: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
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: 02/29/2024
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process

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.

During the exit interview, the Licensee Broom-Jackson, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.



A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with the licensee Lori Broom-Jackson.
SUPERVISORS NAME: Chandra Charles
LICENSING EVALUATOR NAME: April Wright
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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