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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400222
Report Date: 04/25/2025
Date Signed: 05/22/2025 01:41:19 PM

Document Has Been Signed on 05/22/2025 01:41 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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JEFFERSON FAMILY CHILD CAREFACILITY NUMBER:
198400222
ADMINISTRATOR/
DIRECTOR:		SHERMAL JEFFERSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 900-2963
CITY:CERRITOSSTATE: CAZIP CODE:
90703
CAPACITY: 14TOTAL ENROLLED CHILDREN: 5CENSUS: 3DATE:
04/25/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Licensee, Shermal JeffersonTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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On 04/25/2025 at 11:10 am, Licensing Program Analyst (LPA) Jonnisha Culbert performed an unannounced annual/random inspection at the facility noted above. LPA met with Licensee Shermal Jefferson and stated the purpose of today’s visit. LPA provided Licensee with an Entrance Checklist for Family Child Care Homes (LIC 126). Licensee guided LPA on a tour of the facility. Present at the time of inspection were Licensee and 3 children. Individuals residing in the home were discussed and noted. Per licensee, the operating hours are Monday through Friday from 6am to 6pm.

This is a single-family home that consists of Three (3) bedrooms, two (2) bathrooms, living room, dining area, kitchen, an attached converted garage, fenced backyard, driveway, and front yard.

On limits areas includes one bedroom, one bathroom, kitchen, dining area, attached converted garage, and enclosed backyard.

Off limits areas includes two bedrooms, one-bathroom, and front yard. During inspection LPA observed off limits bedroom doors opened. Per Licensee, they opened them for LPA. LPA reminded Licensee that off limits areas of the home are to remain inaccessible while children are in care.

The following documents were posted inside the converted garage: Facility License, Notification of Parents' Rights (PUB 394), and Earthquake Preparedness (LIC 9148). A Facility Roster (LIC 9040) was not available for review. This is a potential safety risk for persons in care. LPA reminded Licensee to complete and maintain
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2025
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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Document Has Been Signed on 05/22/2025 01:41 PM - It Cannot Be Edited


Created By: Jonnisha Culbert On 04/25/2025 at 02:34 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JEFFERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1597.543
Licensure Requirements
Every family day care home for children shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 Division 12. The department shall account for the presence of these detectors during inspections.

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 and the home did not have one carbon monoxide detector. Per Licensee, they only have the one alarm and they were told it is for both. LPA observe that alram reads 10 year smoke alarm. This poses a potential health and safety risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Per licensee, thier vivint alarm system has a carbon monoxide detector and they will email LPA proof by plan of correction date.
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, the licensee did not comply with the section cited above in 1 out of 1 fire extinguisher was lasted serviced on 03/03/2020 which poses a potential health and safety risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Per Licensee, they will email LPA J. Culbert current service tag or reciept of a newly purchased fire extinguisher.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Jonnisha Culbert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 05/22/2025 01:41 PM - It Cannot Be Edited


Created By: Jonnisha Culbert On 04/25/2025 at 02:34 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JEFFERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025

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 record review, the licensee did not comply with the section cited 1 out of 1 personnel was missing mandated reporter certificate which poses a potential safety risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Per Licensee, they will email LPA J. Culbert a mandated reporter certificate by plan of correction date.
Type B
Section Cited
HSC
1597.622(c)
Administration of Child Day Care Licensing
(c) The family day care home shall maintain documentation of the required immunizations or exemptions from immunization, as set forth in this section, in the person's personnel record that is maintained by the family day care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1out of 1 personnel did not have maintained documentation of the required immunizations which poses a potential health and safety risk to persons in care.
POC Due Date: 05/23/2025
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.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Jonnisha Culbert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/22/2025 01:41 PM - It Cannot Be Edited


Created By: Jonnisha Culbert On 04/25/2025 at 02:34 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JEFFERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025

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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Based on record review, the licensee did not comply with the section cited above and they did not have proof of pediatric cardiopulmonary resuscitation and pediatric first aid pursuant to Health and Safery Code Section 1596.866. This poses a potential health and safety risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Per Licensee, they are going to complete the correct training and email certificate to LPA J. Culbert by plan of correction date.
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
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Based on record review, the licensee did not comply with the section cited above in 1out of 1 child file reviewed was missing their immunizations. This poses a potential health and safety risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Per Licensee, they will obtain child's immunization record from parent and place it in child's file. Also, they will email a copy to LPA J. Culbert by plan of correction 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.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Jonnisha Culbert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/22/2025 01:41 PM - It Cannot Be Edited


Created By: Jonnisha Culbert On 04/25/2025 at 02:34 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
, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JEFFERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400222

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview], the licensee did not comply with the section cited above and they did not have a facility roster. Per Licensee, they do not have a roster. LPA reminded Licensee to ensure that they maintain a current roster at the home. This is a potential safety risk to persons in care.
POC Due Date: 05/23/2025
Plan of Correction
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Per Licensee, they will create a roster and email it to LPA J. Culbert by plan of correction date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Warren Birks
NAME OF LICENSING PROGRAM MANAGER:
Jonnisha Culbert
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JEFFERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400222
VISIT DATE: 04/25/2025
NARRATIVE
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an updated roster. LPA observed Disaster and Fire Drill log. The last drill was conducted on 04/05. LPA reminded licensee that drills are to be conducted every six months and to be sure the year is written on the logs.

Areas used by children were inspected for safety, comfort, heating, cleanliness, and telephone service.


Furniture and equipment were inspected for age appropriateness and good repair. Telephone service, heating, lighting, and ventilation were evaluated. The facility uses central heating and air for ventilation. Lighting was observed to be in operable condition. LPA observed age-appropriate toys indoors and in the outdoor play area (fenced backyard). Per licensee, children play inside of the converted garage and in the backyard. LPA observed cots and three play yards for napping. LPA reminded Licensee to ensure that they are following safe sleep regulations when monitoring and accessing napping infants. Per Licensee, there are no bodies of water or firearms on the premises.

Detergents, cleaning compounds, and medicines were made inaccessible to children. Per Licensee, there are no poisons on the premises and pest control comes every three months to spray. LPA reminded licensee that if poisons are purchased, they are to remain in an area that is locked and inaccessible to children. LPA observed cleaning supplies in inaccessible cabinet underneath the sink in the kitchen.

LPA observed the fire extinguisher (2-A:10-B:C) that is fully charged with a service date of 03/03/2020. Per Licensee they did not know that the extinguisher was to be serviced yearly. This is a potential safety risk to persons in care. LPA reminded Licensee to have the fire extinguisher serviced yearly. LPA observe an operable smoke alarm. Per Licensee, the smoke alarm is for both smoke and carbon monoxide. LPA observed that the alarm reads 10-year smoke alarm. This is a potential safety risk to persons in care. LPA advised Licensee to install a carbon monoxide detector.



Per licensee, they provide breakfast, lunch, and two snacks and one child bring their own meals. Licensee was reminded that food that is brought from the children's home shall be labeled with the child’s name and properly stored or refrigerated.

LPA conducted a record review of 1 child file and 1 personnel file. Based on the children's record review, 1
NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JEFFERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400222
VISIT DATE: 04/25/2025
NARRATIVE
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out of 1 children’s record was missing proof of immunizations. Per Licensee, they thought that Child 1’s immunization record was in their file. This is a potential health and safety risk to persons in care.

Based on the personnel records reviewed, 1 out of 1 file was missing proof of immunization against measles and pertussis, mandated reporter, and a valid pediatric first aid and CPR training certificate. This is a potential health and safety risk to persons in care. LPA reminded licensee that mandated reporter training must be completed every 2 years. Mandated reporter training is available at www.mandatedreprterca.com.

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.

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/.

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JEFFERSON FAMILY CHILD CARE
FACILITY NUMBER: 198400222
VISIT DATE: 04/25/2025
NARRATIVE
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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, Shermal Jefferson, 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 the licensee, Shermal Jefferson.

NAME OF LICENSING PROGRAM MANAGER: Warren Birks
NAME OF LICENSING PROGRAM ANALYST: Jonnisha Culbert
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
LIC809 (FAS) - (06/04)
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