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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405134
Report Date: 12/12/2024
Date Signed: 12/12/2024 04:42:21 PM

Document Has Been Signed on 12/12/2024 04:42 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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:JACOBS, CARMEN DFACILITY NUMBER:
073405134
ADMINISTRATOR/
DIRECTOR:		JACOBS, CARMEN DFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 427-2341
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 0DATE:
12/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Carmen JacobsTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On 12/12/2024 Licensing Program Analyst (LPA) Kareeca "Reeca" Sykes conducted an Unannounced Annual Inspection at Carmen Jacobs Family Child Care Home. LPA met with Licensee Carmen Jacobs and explained the purpose of today’s inspection and was granted entry into the home. There were no children present at time of inspection. Facility is in compliance with required ratios today. Days and hours of operation are 24 Hours Monday-Friday. Licensee and licensee's spouse was present in the home during the inspection and has Criminal Background Check Clearances. Residing in the home are the Licensee, Licensee's husband, and licensee's adult granddaughter who are all fingerprint cleared.

The home is a two-story home that consist of three (3) bedrooms, 2 1/2 bathrooms, living room, family room, kitchen, dining area, fenced backyard, and garage. The children use the bathroom to the left of the front door across from the staircase, living room, dining area, backyard, and garage.

ON LIMIT AREAS: Family room, Dining room, Living room, Kitchen, 1/2 bathroom (Located to the left of the front door), Front yard (with 100% supervision), Backyard, and Garage.
OFF LIMITS: The entire upstairs (Bedroom 1, Bedroom 2, Bedroom 3, Bathroom 1, and Bathroom 2)
Off limit areas will be made inaccessible by closed and/or locked doors, child safety gates, and visual supervision.

The Isolation area: A section on the couch in the family room away from children in care.

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SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Kareeca Sykes
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JACOBS, CARMEN D
FACILITY NUMBER: 073405134
VISIT DATE: 12/12/2024
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Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. There is fireplace in the living room that is screened off and made inaccessible to children in care. There are safe toys, play equipment, and materials observed for children. There is a safety gate at the bottom of the stairs. There is a working telephone in the home. All poisons, cleaning solutions, medications, and other items that pose a danger to children are inaccessible during this visit. The licensee does understand that poison must be in a locked cabinet/drawer or placed out of reach of children. Knives were kept in a locked storage cabinet. The home is equipped with a fully charged 3A40BC fire extinguisher, working smoke and working carbon monoxide detector. Licensee states there are no firearms or pets on the premises. There are no pools, spas, hot tubs, fishponds or similar bodies of water.

FILE REVIEW: Children and Assistant files were reviewed. Licensee’s Mandated Reporter Training is current (expires 04/2026) and CPR/First Aid is current which expires on 03/18/2026.

Licensee was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California

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.

LPA discussed the Safe Sleep regulations with Licensee and 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.
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SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Kareeca Sykes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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 CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JACOBS, CARMEN D
FACILITY NUMBER: 073405134
VISIT DATE: 12/12/2024
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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/.

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 information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

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

In the areas that were evaluated, no regulatory violations were observed.

Exit interview conducted and report was reviewed with Licensee, Carmen Jacobs

A Notice of Site Visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in immediate civil penalty of $100.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Kareeca Sykes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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