198400240-7-29-2025-54-CC-ACAN-DK32ZY-20250729175108

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400240
Report Date: 07/29/2025
Date Signed: 07/29/2025 05:53:30 PM

Document Has Been Signed on 07/29/2025 05:53 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:	JACKSON FAMILY CHILD CARE		FACILITY NUMBER:	198400240
ADMINISTRATOR/ DIRECTOR:	SHAWNTAYZIA A. JACKSON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 556-3416
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 15	CENSUS: 9	DATE:	07/29/2025
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:47 PM
MET WITH:	Licensee/ SHAWNTAYZIA A. JACKSON		TIME VISIT/ INSPECTION COMPLETED:	04:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Ashley Calderon conducted an unannounced annual/ random inspection to the above facility on 07/29/2025. LPA met with Licensee Shawntayzia Jackson who allowed LPA entrance into the facility. Upon entrance LPA observed (3) adults and 9 children present, children were napping. Individuals residing in the home have been discussed and noted. All adults residing, employees and volunteers present in the home have obtained a criminal record clearance or exemption (if applicable). LPA was guided on a tour of the facility alongside Licensee S.Jackson. Per Licensee, operation hours are Monday through Friday from 6AM to 6PM. However, Licensee stated she does extend hours once in a while depending on parents needs. Per Licensee, currently has no infants and no firearms stored in the home. LPA provided FCC Entrance Checklist- LIC126 All areas identified on the facility sketch were inspected that are used by children. This is a one story home that consists of 3 bedrooms, 2 restrooms, dining area, living room, kitchen, sun- room (daycare room), garage, backyard, and front yard. Per Licensee, the children will use the restroom in the hallway, dining, sun-room/ day-care room, living room, and back yard. Areas that will be used by children were observed for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. (Pg 1 / Cont.)

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 198400240
	VISIT DATE: 07/29/2025

NARRATIVE

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LPA reviewed required posted documentation's located in the Sun Room (day care room) for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form (LPA printed LIC9148 to post). Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan. Disaster drill log reviewed and conducted 7/2025.

Smoke and carbon monoxide detector was tested and operable. LPA observed required 2A10BC fire extinguisher with service tag dated 1/31/2024. The home maintains telephone service via cell phone. There are age appropriate equipment, toys and material available for children inside and outside. Isolation area for sick children waiting to be picked up is in the dining area, away from the other children.

Licensee informed LPA there will be a infant enrolling soon. LPA reviewed Infant Safe Sleep Regulations. Per Licensee will use Play yards for infant. LPA reminded Licensee play yards and cribs must have mattresses; shall be firm and covered with a fitted sheet that overlaps the underside so it cannot be dislodged. Play yards are to be free of loose articles and objects when infant is sleeping. LPA reviewed LIC 9227 Infant Sleep Plan for infants under 12 months and 15-minute sleep check documentation for infants 0-24 months. LPA provided PIN 20-24-CCP and provided links where to locate PINS and Subscribe if hasn't done so yet.

Kitchen was observed, there are baby safety latches in cabinets and/or baby safety clips on cabinets for inaccessibility where knives are located and under the sink cabinet there are chemicals and cleaning compounds.

Backyards was observed and is used for children. There are no pools or spas, or other bodies of water. There is a dog at the facility that is kept in an off limit area. There is a locked shed and a portion of the yard has a baby safety gate to provide inaccessibility to children.

Staff records were reviewed. Licensee Pediatric 1st aid and cpr expired 6/2025, picture taken of expired certificate, deficiency cited and Licensee Mandated Reporter expires 1/31/2026. Staff assistant (resident living in the home) needs to take certifications Mandated Report and immunization's not in file, deficiencies cited. LPA conducted staff interview with Licensee. LPA reminded Licensee on volunteer requirements for a Family Child Care Home, volunteers cannot be left with children alone, need vaccination records and cannot exceed 16 hours a week. During the visit Licensee updated LIC279B Current Children living in the home. Licensee has (2) children under 10 years old living in the home. LPA informed Licensee children are included in the day care census when present with day care children are at the facility.
(Pg 2 /Cont.)

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

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
MONTEREY PARK SW RO, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 198400240
	VISIT DATE: 07/29/2025

NARRATIVE

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Children files were reviewed, (6) files. Consultation was given for LIC995A Parent Rights forms 2 out of 6 missing form and Consultation was giving for 1 out of 6 children for immunization record not in 1 child's file per Licensee child is unenrolling this week. All other required forms were in children files: Emergency Identification Form, Consent for Medical Treatment, Parent Rights and Immunization Records (if applicable). LPA informed Licensee children enrolled in school no not need Immunization records and need a form stating they are enrolled in school.

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-and-resources/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, the Licensee, 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 will be emailed and must remain posted for 30 days. Based on today’s visit, Per California Code of Regulations Title 22, the facility was given (3) deficiencies, Type B, provided on LIC 809-D, Reports will be emailed due to printing issues. An exit interview was conducted with Licensee Shawntayzia Jackson (Pg 3/ End of report)

NAME OF LICENSING PROGRAM MANAGER: Denise Gibbs
NAME OF LICENSING PROGRAM ANALYST: Ashley Calderon
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/29/2025 05:53 PM - It Cannot Be Edited

Created By: Ashley Calderon On 07/29/2025 at 04:06 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: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 198400240
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2025

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
1 2 3 4	Based on record review Staff Assistant did not have mandated reporter training in file, Licensee did not provide certificate for Staff assistant, the licensee did not comply with the section cited above in [1] out of [1] staff assistant Mandated Reporter -Child Care Provider which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2025
	Plan of Correction
1 2 3 4	Staff assistant will take Mandated Reporter -Child Care Provider (4 hr) training and send certficate to LPA Calderon by poc due date.

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
1 2 3 4	Based on LPA Calderon record review staff assistant did not have immunization records - TDap, MMR, TB and Influenza, the licensee did not comply with the section cited above in [1] out of [2] staff immunization records which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2025
	Plan of Correction
1 2 3 4	Staff assistant will obtain immunization records for- TDap, MMR, TB and Influenza (can decline flu) or will get immunization's done if needed and send copies of records to LPA Calderon.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Denise Gibbs
NAME OF LICENSING PROGRAM MANAGER:

	Ashley Calderon
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/29/2025 05:53 PM - It Cannot Be Edited

Created By: Ashley Calderon On 07/29/2025 at 04:28 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: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 198400240
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/29/2025

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
1 2 3 4	Based on record review Licensee Pediatric First aid and CPR expired in June of 2025, picture taken of certficate, the licensee did not comply with the section cited above in [1] out of [1] Licensee Pediatric First aid and CPR expired which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/29/2025
	Plan of Correction
1 2 3 4	Licensee will take Pediatric First aid and CPR and send a copy to LPA Calderon by poc due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Denise Gibbs
NAME OF LICENSING PROGRAM MANAGER:

	Ashley Calderon
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/29/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

LIC809 (FAS) - (06/04)

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