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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075700205
Report Date: 10/14/2025
Date Signed: 10/14/2025 11:23:27 AM

Document Has Been Signed on 10/14/2025 11:23 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: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: 4DATE:
10/14/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Karina JimenezTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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On October 14, 2025 at 9:15am, Licensing Program Analyst (LPA) Julia Placencia arrived at the facility unannounced to conduct an Annual/Random Inspection. LPA met with licensee Karina Jimenez. The facility is a one story single family home. Hours of operation for child care are Monday through Friday, 7:30am to 5:00pm. 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 four (4) infants in care. The facility is in compliance with ratio and capacity.

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. Per licensee, due to low enrollment, she is currently only using the front infant room on the left side and the first bedroom. 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 and is screened and tied shut. 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.


***Continued on LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Julia Placencia
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2025
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: JIMENEZ, KARINA
FACILITY NUMBER: 075700205
VISIT DATE: 10/14/2025
NARRATIVE
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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.

Emergency Preparedness/Safety: Fire extinguisher, smoke and carbon monoxide detectors meet state fire marshal standards. First aid supplies are available. 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 has proper criminal background and TB clearances. Licensee has current CPR/First Aid training expiring on 10/11/27, and her mandated reporter training expires 9/30/27. Licensee is in compliance with immunization law.

Children’s Records Review: Children's files were reviewed and contain all required licensing documents. 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...
NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Julia Placencia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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: JIMENEZ, KARINA
FACILITY NUMBER: 075700205
VISIT DATE: 10/14/2025
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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 deficiency was cited during today’s inspection:
  • Licensee is overdue for a fire/disaster drill as the last drill was conducted on 9/3/24.

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.

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.
NAME OF LICENSING PROGRAM MANAGER: Jason Jang
NAME OF LICENSING PROGRAM ANALYST: Julia Placencia
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2025 11:23 AM - It Cannot Be Edited


Created By: Julia Placencia On 10/14/2025 at 10:52 AM
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: 10/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
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. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the last fire/disaster drill was conducted on 9/3/24, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2025
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 10/21/25.

***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.
Jason Jang
NAME OF LICENSING PROGRAM MANAGER:
Julia Placencia
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2025


LIC809 (FAS) - (06/04)
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