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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075700205
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:26:46 PM

Document Has Been Signed on 10/15/2024 02:26 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, KARINAFACILITY NUMBER:
075700205
ADMINISTRATOR/
DIRECTOR:		JIMENEZ, KARINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 248-3508
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 12DATE:
10/15/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Karina JimenezTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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On October 15, 2024 at 9:15am, Licensing Program Analyst (LPA) Julia Placencia arrived at the facility unannounced to conduct an Annual/Random Inspection. LPA initially met with helper Maria Caecedo as licensee Karina Jimenez was at a doctor's appointment. Licensee returned at 9:40am and helper Claudia Garcia Ortiz arrived at 10:00am. Licensee had to leave again at 10:30am for another doctor's appointment and returned at 1:50pm. Also residing in the home is the licensee's 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 twelve (12) children in care (eight preschoolers and four infants), and two helpers (Claudia Garcia Ortiz and Maria Caecedo).

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 were ample age appropriate toys inside that were observed to be safe and in good condition. The backyard has a fence surrounding the perimeter of the yard. There were no pools, hot tubs or other bodies of water. 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 LIC809-C...
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 10/15/2024
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Emergency Preparedness/Safety: Fire extinguisher, smoke and carbon monoxide detectors meet state fire marshal standards. First aid supplies are available. A last fire/disaster drill was documented on 12/11/23. 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 and TB clearances. Licensee has current CPR/First Aid training, which expires on 4/23/25. Licensee’s mandated reporter training expires 9/29/25. New employee Maria is advised to take the training within 90 days of her hiring date. Licensee and Claudia are in compliance with immunization law.

Children’s Records Review: Children's files were reviewed. Licensee maintains infant plans for infants up to 12 months old and sleep logs 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 LIC809-C...
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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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: 10/15/2024
NARRATIVE
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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.

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.

The following deficiencies were observed during today’s inspection:
  • Upon arrival to the facility licensee, helper Maria Caecedo was alone with 12 children while licensee was at a doctor's appointment.
  • Also upon arrival, LPA observed four infants sleeping in two separate bedrooms with the doors closed (one infant in first bedroom, three in the second bedroom).
  • Helper Maria Caecedo does not have First Aid/CPR training and was alone with the children while licensee was at a doctor's appointment.
  • The last fire/disaster drill was documented on 12/11/23.

***Continued on LIC809-C...
SUPERVISORS NAME: Jason Jang
LICENSING EVALUATOR NAME: Julia Placencia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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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: 10/15/2024
NARRATIVE
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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.

The attached type A violation is cited today and must be corrected by the due date. Upon receipt, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. All parents/guardians must sign an acknowledgement form of proof of receiving this report (LIC 9224). The LIC 9224 must be placed in each child's file to be reviewed by licensing.

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: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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Document Has Been Signed on 10/15/2024 02:26 PM - It Cannot Be Edited


Created By: Julia Placencia On 10/15/2024 at 01:09 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: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102416.5(e)
Staffing Ratio and Capacity
(e) If no assistant provider is present at a Large Family Child Care Home, then the licensee shall comply with the capacity requirements for a Small Family Child Care Home as specified in subsections (b) and (c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee's helper was alone with twelve children (four infants and eight preschoolers) while licensee was away for a doctor's appointment, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/16/2024
Plan of Correction
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Licensee shall ensure she stays within the ratio/capacity limits of her license and submit statement of compliance by due date of 10/16/24. ***LPA may return to confirm compliance***
***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.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 02:26 PM - It Cannot Be Edited


Created By: Julia Placencia On 10/15/2024 at 01:09 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: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the fire/disaster drill was documented on 12/11/23, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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Licensee shall conduct a fire/disaster drill, document on log and submit copy of log to LPA by due date of 10/22/24.

***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.
Type B
Section Cited
CCR
102425(j)(5)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: If the infant is sleeping in a separate room from where the provider is stationed, the door to the room the infant is sleeping in shall remain open at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, infants were sleeping in napping rooms with the doors closed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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LIcensee shall ensure doors to the rooms where infants are sleeping remain open. Submit statement of compliance to LPA by due date of 10/22/24.
***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.
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: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 02:26 PM - It Cannot Be Edited


Created By: Julia Placencia On 10/15/2024 at 01:09 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: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on record review, licensee's helper was alone with the children and does not have First Aid/CPR training, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2024
Plan of Correction
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LIcensee shall ensure helper completes First Aid/CPR training and submit proof of class registration, or confirm helper shall not be alone with the children, by due date of 10/22/24. Additionally submit certificate when class has been completed.
***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.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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