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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197406067
Report Date: 06/25/2025
Date Signed: 06/25/2025 01:11:46 PM

Document Has Been Signed on 06/25/2025 01:11 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:JACKSON FAMILY CHILD CAREFACILITY NUMBER:
197406067
ADMINISTRATOR/
DIRECTOR:		JACKSON, CAROLYN J.FACILITY TYPE:
810
ADDRESS:TELEPHONE:
(323) 299-0546
CITY:LOS ANGELESSTATE: CAZIP CODE:
90043
CAPACITY: 14TOTAL ENROLLED CHILDREN: 12CENSUS: 2DATE:
06/25/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:49 AM
MET WITH:Licensee, Carolyn JacksonTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Dawn Dowling conducted an unannounced annual required inspection at the above facility on 06/25/2025 at 08:50 AM. Upon arrival, LPA disclosed the purpose of the inspection and met with Carolyn Jackson Licenses who guided LPA on a tour of the facility. Entrance Checklist – Family Child Care Homes LIC 126 was provided to the Licensee’s to help facilitate the inspection. Licensee employes an assistant that arrives at 10:00 am to assist with the children. There were two day care children present during today’s inspection. Per Licensee, there are currently twelve children enrolled. Facility capacity is in compliance for a large Family Child Care Home. Hours of operation are Mon-Fri 06:00 AM - 6:00 PM.

LPA toured the home inside and outside. This is a two story home which consists of 5 bedrooms, 3 bathrooms, kitchen, dining room, living room, laundry room, detached craft room, front yard and backyard (fenced). The front of the home is off limits, 5 Bedrooms, 2 bathrooms, Living Room, Kitchen, laundry room, detached craft room and front yard. The dining room/Den (Child Care room) and bathroom off of dining room/Den is accessible to children in care . Child care families access the day care through the side door of the home.



Individuals residing in the home have been discussed and noted, Licensee is the only one that resides in the home. Assistant arrived at 9:52 AM and has obtained a criminal record clearance and is associated with Guardian background check system.

Smoke and carbon monoxide detectors were tested and are operable. Fire extinguisher at least 2 years old and Licensee reminded to have extinguisher serviced or purchased every year to ensure they are functional as Licensee indicates it may have been 2 years when the fired department came out and over a year when fire extinguisher that was in the box was purchased.


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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 197406067
VISIT DATE: 06/25/2025
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LPA Dowling informed Licensee that it when the fire extinguisher is serviced it is generally tagged with date of service to let you know when you will need to get it serviced next year. This will result in a Type B deficiency to allow Licensee time to either purchase a new one and show proof with receipt attached via photograph or serviced with tag indicating date of service.

The home maintains telephone service via landline . The home is observed to be clean and orderly. There are toys and other age-appropriate materials available for children. Children have their own cubbies to put their belongings in, they use mats for sleeping and bring their own bedding that is taken home every friday and washed. Home has central air and heating. The stairs to access upstairs has a gate to make it inaccessible to children in care. LPA observed knives stored in kitchen on top of refrigerator, cleaning compounds are located in main bathroom which is inaccessible to children in care. Licensee has medication stored in her room upstairs which in inaccessible to children. Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in child care room, child will be kept away from the other children. Per Licensee/FR there are no firearms or weapons stored in the home.

Infant Care: Licensee does not currently care for any children 24 months of age or younger.

Overnight Care: Licensee does not provide overnight care.

Currently, children are using the back yard for outdoor play. The outdoor play area was observed to be fenced. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA observed plastic play house with various broken pieces that could result in possibly injury to children in care and informed Licensee not to utilize play house until repaired to prevent any potential injures to children in care. The broken piece could be hazardous to children in care and will result in a Type B deficiency Licensee will take photographs and send to LPA once corrected. There are no pools or spas, or other bodies of water.


Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance,LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights were observed to be in the children's files. Two of the children's files did not have immunization records-LPA Dowling discussed with Licensee that children's files are to have the required proof of immunization for Tdap(Pertussis), Measles, Mumps Rubella (MMR), this will result in a Type B deficiency.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 197406067
VISIT DATE: 06/25/2025
NARRATIVE
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Staff records were reviewed for approved Pediatric First Aid and CPR certification, LIC-501: Personnel Record, LIC 508- Criminal Record Statement, LIC 9052- Employee Rights, LIC 9108- Acknowledging Requirement to Report Child Abuse..
— Pediatric First Aid and CPR expires: 06//2027 for Staff and 4/2027 for Licensee.

LPA did not observe proof of immunization against measles, pertussis. Licensee provided influenza declination. There was no TB clearance or risk assessment in staff files. Licensee and Staff do not have current Mandated Reporter AB 1207 Certificate on file, LPA Dowling discussed with Licensee that this is renewed every 2 years like Pediatric First Aid and CPR and will result in a Type B Deficiency which Licensee indicates she will go online and take and instruct staff to do the same and will provide LPA Dowling proof of completion by send certificate to LPA Dowling via email once completed.

During inspection all children were observed to be treated with dignity and respect, they were observed to be receiving safe, healthful, and comfortable accommodations, furnishings and equipment, and free from corporal and/or unusual punishment.

Incidental Medical Services (IMS): Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual – Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm



Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.



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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC809 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 197406067
VISIT DATE: 06/25/2025
NARRATIVE
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Licensee was reminded of their responsibility to report suspected child abuse. Mandatory Forms for the children’s files and provider’s files were discussed. Licensee was made aware that state law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. Licensee was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome), and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome.

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. Licensee was also reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.

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

The licensee was advised the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, (Type A violation), a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. The applicant was made aware that a licensee may file an appeal, in writing 15 business days from the date of receiving the penalty assessment.

During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809D (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Deficiencies that are being cited need to be cleared to protect the children’s health & safety.

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NAME OF LICENSING PROGRAM MANAGER: Raul Navarro
NAME OF LICENSING PROGRAM ANALYST: Dawn Dowling
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 06/25/2025 01:11 PM - It Cannot Be Edited


Created By: Dawn Dowling On 06/25/2025 at 12:31 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 197406067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(d)
Operation of A Family Child Care Home
(d) The home shall provide safe toys, play equipment and materials.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 of the outside toys (play house) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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Licensee will remove broken plastic pieces and cover floor of play house out prevent any potential injuries and will send LPA Dowling photograph of correction via email.
Type B
Section Cited
CCR
102417(g)(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: (1) Fireplaces and open face heaters shall be screened to prevent access by children. The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshall.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2 fire extinguishers were not serviced within the year which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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Licensee will take fire extinguishers to fire department or will purchase a new one and take photograph with receipt and send to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Dawn Dowling
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 06/25/2025 01:11 PM - It Cannot Be Edited


Created By: Dawn Dowling On 06/25/2025 at 12:31 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 197406067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on(observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 3t persons do not have mandated reporter training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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Licensee and staff will take Mandated Reporter Training, once completed will provide proof of certificate to LPA Dowling via email.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 3 out of 3 persons do not have proof of immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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Licensee will look for her immunization record and will have staff provide immunization record and send copy to LPA Dowling on or before POC due date via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Dawn Dowling
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 06/25/2025 01:11 PM - It Cannot Be Edited


Created By: Dawn Dowling On 06/25/2025 at 12:31 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 197406067

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/25/2025

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 observation and record review, the licensee did not comply with the section cited above in 2 out of 2 persons do not have proof of immunization which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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2
3
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Licensee will inform parents of children for copies of immunization record and will send to LPA Dowling via email.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Raul Navarro
NAME OF LICENSING PROGRAM MANAGER:
Dawn Dowling
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
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