013423437-4-21-2025-52-CC-AWRT-DFXMXW-20250421100037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013423437
Report Date: 04/17/2025
Date Signed: 04/21/2025 10:00:48 AM

Document Has Been Signed on 04/21/2025 10:00 AM - 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, GERALDEAN		FACILITY NUMBER:	013423437
ADMINISTRATOR/ DIRECTOR:	BROOM-JACKSON, LORI		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 501-8776
CITY:	FREMONT	STATE: CA	ZIP CODE:	94555
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 0	DATE:	04/17/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Lori Broom-Jackson		TIME VISIT/ INSPECTION COMPLETED:	03:55 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On April 17th, 2025 at approximately 2:15pm, Licensing Program Analyst (LPA) April Wright met with licensee Lori Broom-Jackson for an Annual Random Inspection. LPA disclosed the purpose of the inspection and was granted entry into the facility by the licensee. There were no children present during the inspection. 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 including master bedroom, three and one half bathrooms including master bathroom, 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 area which is a section away from other children in care. LPA observed and licensee confirmed that there are no hazardous materials, including cleaning products, medicines, chemicals or toxins present during the inspection. The backyard is completely fenced and is free from visual damage and hazards as observed by the LPA. On limit areas: 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 potential rain/flooding risks. Licensee uses park down the street from the home for outside when weather permits. Off-limits areas: Second floor: Remaining three bedrooms and three bathrooms, Side portion of back yard, loft, laundry room and garage. The off limits area 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. 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.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: April Wright
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/17/2025

NARRATIVE

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LPA observed and Licensee confirmed that there are no pools, hot tubs or any other bodies of water present in home. LPA observed and licensee confirmed that there are no pets, weapons or firearms in the home.

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 1/16/2025. The licensees and assistants have a current CPR/First aid certificate which expires on 8/2025 and Mandated Reporter was completed on 12/12/2024. The licensee is in compliance with the immunization laws which pertains to all childcare providers. Licensee was reminded that training certificates must be renewed every 2 years. 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.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: April Wright
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

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: 04/17/2025

NARRATIVE

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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/.

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. Report was read and reviewed with licensee Lori Broom-Jackson.

NAME OF LICENSING PROGRAM MANAGER: Chandra Charles
NAME OF LICENSING PROGRAM ANALYST: April Wright
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2025

LIC809 (FAS) - (06/04)

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