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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 344500805
Report Date: 03/22/2023
Date Signed: 03/22/2023 11:13:14 AM

Document Has Been Signed on 03/22/2023 11:13 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:JACKSON, JANAFACILITY NUMBER:
344500805
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jana JacksonTIME COMPLETED:
11:30 AM
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On 03/22/2023, Licensing Program Analyst Katy Maestas (LPA) met with Applicant Jana Jackson (A1) for the purpose of a pre-licensing inspection. A1 had a change of location from license #343619244 to the current license #344500805. LPA disclosed the purpose of the inspection and was granted entrance into the Family Childcare Home (FCCH). LPA provided the Entrance Checklist to A1. All individuals subject to criminal background review have obtained a criminal record clearance verified by LPA accessing Guardian. A1’s tentative hours of care are Monday through Friday, from 6:00 AM until 5:00 PM. A1 does not intend on providing overnight or weekend care.

A health and safety inspection was conducted inside and outside of the FCCH. A1 accompanied LPA for the entirety of the tour. The FCCH is a one-story house with a kitchen, living room, 2 bathrooms, 3 bedrooms, master bedroom and bathroom, and 2 garages. LPA verified that toxic and hazardous items were inaccessible to children in care. LPA did not observe any stairs nor fireplaces. The outdoor play area was toured which includes the backyard, patio, side yards and front yard. A1 stated that she may also use a local playground for outside play. LPA verified that the entirety of the backyard is fenced-in and observed the perimeter to ensure the safety of the fence and gate. LPA did not observe any pool, spa nor water feature. A1 stated that she does not own any pets. The OFF-limits areas of the FCCH are garage #2, bedroom #3, and bedroom #4. A1 understands that OFF-limits areas must remain inaccessible to children in care.

A functioning dual smoke and carbon monoxide detector was observed in the hallway and tested. LPA observed cleaners stored in the kitchen and bathroom cabinets that have child safety locks on the cabinet doors. LPA observed detergents to be stored in the laundry room behind cabinet doors with child safety locks. Medications were observed to be stored in the kitchen and bathrooms on top shelves that are out of reach to children in care. A 2A10BC fire extinguisher was observed and appeared to be in the green zone, and a first aid kit was observed in the kitchen. A1 stated there are no firearms nor weapons in the home.


LPA discussed Mandated Reporter Training with A1. Health and Safety Code 1596.8662 requires all licensed Continued on 809-C
SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2023
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: JACKSON, JANA
FACILITY NUMBER: 344500805
VISIT DATE: 03/22/2023
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providers, applicants, directors and employees to complete training as specified on their Mandated Reporter duties and to renew their training every 2 years. Volunteers are encouraged but not required to take the training. This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com. The training is currently provided in English and Spanish. A1 has a current Mandated Reporter Training Certificate which will expire on 02/23/2025. Current Pediatric CPR and First Aid training was verified for A1 and expires on 06/18/2024. Completion of Preventative Health and Safety training, including nutrition and lead exposure, was verified before the inspection. Proof of required immunizations for A1 was also verified before the inspection.


LPA discussed the Safe Sleep Regulations with A1 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 A1 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. LPA discussed the requirement to check and log infant napping every 15 minutes for infants under 24 months old. LPA provided a copy of the LIC 9227/Individual Sleeping Plan to be completed for infants under 12 months old.

APPLICANT WILL WAIT UNTIL FACILITY OPENS TO DETERMINE IMS NEEDS: 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: http://www.ada.gov/childqanda.htm

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.

Continued on 809-C

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: JACKSON, JANA
FACILITY NUMBER: 344500805
VISIT DATE: 03/22/2023
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To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

A1 was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

A1 understands that licenses are not transferable, and once licensed, Licensee must live in the home and be present for 80% of the operating hours. A1 understands that if an unusual incident occurs; Licensing is to be notified via phone call, e-mail or fax within 24 hours and the LIC 624/ Unusual Incident Report shall be submitted within 7 days to remain in compliance. A1 understands that if any structural changes are made to the FCCH; Licensing must be notified PRIOR to construction.



A1 understands that if she wants to make any OFF-limits area an ON-limits area, she must notify Licensing and LPA must do an inspection BEFORE children are allowed in said area. A1 understands that children’s and staff’s records are to be maintained according to Title 22 regulations and be accessible to Licensing for up to 3 years. LPA reviewed with A1 the LIC 311D Forms/Records To Keep In Your Family Child Care Homes, Children’s Forms/Records, Facility Forms/Records, and Information to be Posted. A1 understands that fire drills must be conducted and documented once every 6 months.

As of today, 03/22/2023, A1 is approved for a Small Family Child Care Home license for a capacity of 8 children with no more than 3 infants, or 4 infants only, OR up to 8 children with no more than 2 infants and 1 child in Transitional Kindergarten or above and 1 child at least age 6 years. Infants are children under the age of 2 years old.

An exit interview was conducted, and the report was reviewed with A1. Licensee Appeal Rights were provided by LPA. A Notice of Site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023
LIC809 (FAS) - (06/04)
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