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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400222
Report Date: 07/28/2021
Date Signed: 07/28/2021 03:24:28 PM

Document Has Been Signed on 07/28/2021 03:24 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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JEFFERSON FAMILY CHILD CAREFACILITY NUMBER:
198400222
ADMINISTRATOR:SHERMAL JEFFERSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 900-2963
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
07/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shermal Jefferson, LicenseeTIME COMPLETED:
03:45 PM
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Visit Conducted in English

An unannounced Required One Year Inspection was conducted by Licensing Program Analyst (LPA) A. Lucero. Prior to arrival to the facility, LPA phoned facility at 1:00pm to conduct COVID-19 pre-screening questions. During the COVID-19 pre-screening questions, it was stated that the facility is not aware of any staff or children having been exposed to COVID-19 persons within the last 14 days, no staff or children currently have COVID-19 related symptoms, and all staff are wearing facial masks as required. Licensee stated she currently does not have any children enrolled.

LPA met with licensee Shermal Jefferson who guided LPA on a tour of the facility. This is a single story, three bedroom, two bathroom home. People who live in the home have been noted and clearance has been reviewed.

Areas accessible to children were inspected as follows: Living room, dining area, one bathroom located in hallway, and back yard.
Areas off limits include: All three bedrooms, attached garage, one bathroom located in master bedroom, front yard.

Licensee states that there are no weapons or firearms on the premises. LPA did not observe swimming pools or spas on the premises. The backyard is adequately fenced. There are age appropriate toys and equipment on the premises. The smoke detectors and carbon monoxide detectors is a dual device, is present in the facility and in operable condition. Fire extinguisher is present in the facility. Annual fees are not current.

—CPR Card valid until: American Heart Association and states Pediatric First Aid, Child/Infant CPR, AED with a renewal date of 05/2022
—Child Care Roster and Disaster Plan were reviewed
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE: DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/28/2021
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JEFFERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400222
VISIT DATE: 07/28/2021
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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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm

The following was discussed with the Licensee:

Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearances prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.

In the absence of the Licensee, a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR & Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.

A current roster of children enrolled must be available and maintained for a period of three years, even after children no longer are attending the facility. Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License shall be terminated.

The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and Carbon Monoxide detectors should be checked and batteries replaced as needed. Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.

Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing. Fire and safety drills must be performed every six months and documented for review by the Department. Smoking is prohibited in a family child care home. Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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
CCLD Regional Office, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JEFFERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400222
VISIT DATE: 07/28/2021
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Baby walkers, saucer chairs, bouncers or any similar items are prohibited. Sudden Infant Death Syndrome (SIDS) and Never-Shake-a-Baby were discussed. LPA provided a complete packet of the Provider Information Network (PIN) 10-02-CCP dated February 20, 2019 regarding Safe Sleep Awareness Campaign during today’s inspection.

All adults living and working in the home shall be made of aware of the Departments right to inspection authority, which includes but not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.

· Dog(s) and/or pets should be isolated from children in care.
· It is recommended that First-Aid kits be available on premises.
· Outdoor supervision required at all times. If outdoor area not adequately fenced, provider must be with children at all times when outdoors.

These forms may also be downloaded from our website: www.ccld.ca.gov

There were no deficiencies cited during today's visit in accordance to the California Code of Regulations Title 22, Division 12, Chapter 1

Exit interview, copy of report was given. Appeal rights were issued and discussed.
SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Armando J Lucero
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
LIC809 (FAS) - (06/04)
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