075700205-10-13-2023-52-CC-JPLA-CWKRKN-20231013130548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 075700205
Report Date: 10/13/2023
Date Signed: 10/13/2023 01:05:59 PM

Document Has Been Signed on 10/13/2023 01:05 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:	JIMENEZ, KARINA		FACILITY NUMBER:	075700205
ADMINISTRATOR:	JIMENEZ, KARINA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(650) 248-3508
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 14	CENSUS: 10	DATE:	10/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Karina Jimenez		TIME COMPLETED:	01:15 PM

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On October 13, 2023 at 9:25am, Licensing Program Analyst (LPA) Julia Placencia arrived at the facility unannounced to conduct a Required-1 Year Inspection. LPA met with licensee Karina Jimenez. Also residing in the home is the licensee's brother Bruno Jimenez Rojas and sister Karin Jimenez. The facility is a one story single family home. Hours of operation for child care are Monday through Friday, 7:30am to 5:30pm. The following was observed during today’s inspection:

Capacity/Staffing: The facility operates as a Family Child Care Home (large), which may have a maximum capacity of twelve (12) to fourteen (14) children. At time of inspection, there were ten (10) children in care (eight preschoolers and two infants), and two helpers (Claudia Quiroz and Claudia Garcia Ortiz). The facility is in compliance with ratio and capacity limitations.

ON Limit areas (accessible to children in care): Two child care rooms at front of house, three bedrooms for napping infants in pack-n-plays, hallway bathroom, backyard. Children walk through the OFF LIMIT living room to go to the backyard and are supervised. The fireplace is in the OFF LIMIT family room. LPA observed the facility to be clean and in good repair, with heating and ventilation for safety and comfort. There are ample age appropriate toys that are observed to be safe and in good condition. The backyard has a fence surrounding the perimeter of the yard. There was a small, approximately one foot high inflatable swimming pool empty of water. Licensee understands wading pools must be emptied after each use. LPA did not observe any dangerous conditions, nor any hazardous or toxic items accessible to children in the ON Limit areas of the facility today.

OFF Limit areas (not accessible to children in care): Kitchen, family room, office, master bathroom, both side yards, garage, Off limit areas are inaccessible by closed and/or locked doors and visual supervision. Licensee is aware she must contact Licensing so that an inspection can be completed prior to changing an off limits area to on limits.

***Continued on LIC 809C...

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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: JIMENEZ, KARINA	FACILITY NUMBER: 075700205
	VISIT DATE: 10/13/2023

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Emergency Preparedness/Safety: Smoke detectors, smoke and carbon monoxide detectors meet state fire marshal standards. First aid supplies are available. A fire/disaster drill was last conducted 6/6/23 and meets the six month requirement. Facility has phone service. Per licensee, there are no firearms in the home. Emergency Disaster Plan is current (6/24/19).

Staff Records Review: Licensee and all adults living and/or working in the home have proper criminal background clearances. Licensee has current CPR/First Aid training, which expires on 4/23/25. Licensee’s mandated reporter training expires 9/29/25 and helper Claudia Quiroz's expires 4/8/25. New employee Claudia Ortiz will be taking training soon. Licensee and Claudia Quiroz are in compliance with immunization law.

Children’s Records Review: Children's files were reviewed. Licensee maintains an infant sleep log for infants up to 24 months. A facility roster is maintained.

Licensing Posting (required): Facility license, Notification of Parents’ Rights, Earthquake Preparedness.

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 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.

***Continued on LIC 809C...

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

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: JIMENEZ, KARINA	FACILITY NUMBER: 075700205
	VISIT DATE: 10/13/2023

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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.

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/.

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.

The following deficiencies were observed during today’s inspection:

Children's immunizations have not been transferred onto the blue immunization cards (CDPH 286).
Infant Sleep Plan (LIC 9227) is not on file for infant's under 12 months old.

See LIC809D for deficiencies cited during today's inspection. Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250 per violation and $100 per day until corrected.
Please see LIC 9102 for Advisory Notes.

During the exit interview, licensee 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 licensee Karina Jimenez.

SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/13/2023 01:05 PM - It Cannot Be Edited

Created By: Julia Placencia On 10/13/2023 at 12:30 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
, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612

FACILITY NAME: JIMENEZ, KARINA	FACILITY NUMBER: 075700205
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102418(g)

Immunizations

(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as children's immunizations weren't transferred onto the blue immunization cards (CDPH 286), which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Licensee shall transfer children's immunization records onto the blue immunization cards and submit copies to LPA by due date of 10/23/23.

Type B

Section Cited

CCR

102425(c)

Infant Safe Sleep

An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as completed infant sleep plans were not in children's files, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Licensee shall ensure infant sleep plans (LIC 9227) are completed for infants up to 12 months old and submit a statement ensuring compliance of this regulation by due date of 10/23/23.

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:

Jason Jang

LICENSING EVALUATOR NAME:

Julia Placencia

LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023

LIC809 (FAS) - (06/04)

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