<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 034500273
Report Date: 06/24/2021
Date Signed: 06/24/2021 04:55:23 PM

Document Has Been Signed on 06/24/2021 04:55 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:CLARK, JENNAFACILITY NUMBER:
034500273
ADMINISTRATOR:CLARK, JENNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 217-8287
CITY:PIONEERSTATE: CAZIP CODE:
95666
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 10DATE:
06/24/2021
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Jenna ClarkTIME COMPLETED:
04:55 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 6/24/21 Licensing Program Analyst (LPA) Aruna Sridharan met with licensee Jenna Clark for the purpose of annual inspection. LPA followed infection control protocols. Today's census was 10 children which included 2 school age children 6 preschool children and 2 infants. All adults present had fingerprint clearances. The hours of operation are Monday through Friday from 6:00am to 6:00pm.

A tour of the home, inside and outside, as shown on the facility sketch was conducted. Off-limit rooms are entire upstairs and two bedrooms in first floor. Licensee acknowledges that children may never enter these off-limit areas. The fireplace is barricaded. The backyard is fenced. Licensee stated there are no weapons and no water bodies. LPA observed cleaning supplies like bleach and cleaners under the bathroom sink which is an immediate health and safety risk to children in care. Fire extinguisher and smoke detector meet regulations. There was no carbon monoxide detector at the facility which is a potential risk to the health and safety of children. Safe toys and play equipment are observed. LPA observed all the required postings, reviewed 6 childrens records. Licensee had Pediatric CPR/FA certification which has expired. LPA reviewed children's roster and fire drill log. The last fire drill was conducted on 06/2021.

The facility is following all the Covid precautions while providing care for children. LPA discussed the Safe Sleep regulations.

Title 22 Deficiencies observed in the areas that were evaluated are listed on 809D page. LPA reviewed report with the Licensee and provided copies. An exit interview was conducted. Appeal rights provided. Notice of Site Visit was provided, and licensee understands it must remain posted for 30 days.
SUPERVISORS NAME: Sharon Ogbodo
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
Document Has Been Signed on 06/24/2021 04:55 PM - It Cannot Be Edited


Created By: Aruna Sridharan On 06/24/2021 at 04:42 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: CLARK, JENNA
FACILITY NUMBER: 034500273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2021
Section Cited
CCR
102416(c)

1
2
3
4
5
6
7
The licensee...shall complete.....
CPR and First Aid.
This regulation was not met as evidenced by:
Licensee did not have a valid CPR/First aid certification.
1
2
3
4
5
6
7
Licensee will complete the CPR/First Aid certification and submit proof of completion by the POC date.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Sharon Ogbodo
LICENSING EVALUATOR NAME:Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 06/24/2021 04:55 PM - It Cannot Be Edited


Created By: Aruna Sridharan On 06/24/2021 at 04:25 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
, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: CLARK, JENNA
FACILITY NUMBER: 034500273

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2021
Section Cited
CCR
102417(g)(4)

1
2
3
4
5
6
7
Detergent, cleaning compounds ...shall be stored where they are inaccessible to childlren. This regulation was not met as evidenced by:
Clorox and cleanin
1
2
3
4
5
6
7
Licensee removed the bleach and cleaning product immediately and placed it in an inaccessible area.
8
9
10
11
12
13
14
Clorox and cleaning products were below the bathroom sink cabinet in easy access to children. The cabinet door did not have child safety latch.
8
9
10
11
12
13
14
Type B
07/26/2021
Section Cited
HSC1597.455(b)

1
2
3
4
5
6
7
A small family daycare home...shall have one or more carbon monoxide detectors......during inspections. This health and safety code was not met as evidenced by:
1
2
3
4
5
6
7
Licensee will send proof of installing a functioning carbon monoxide in the facility by the POC date.
8
9
10
11
12
13
14
Licensee did not have a functioning carbon monoxide in the small family child care home.
8
9
10
11
12
13
14
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:Sharon Ogbodo
LICENSING EVALUATOR NAME:Aruna Sridharan
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3