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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 354416074
Report Date: 06/16/2021
Date Signed: 06/16/2021 12:53:40 PM

Document Has Been Signed on 06/16/2021 12:53 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:MEIER-JEWETT, JACQUELINEFACILITY NUMBER:
354416074
ADMINISTRATOR:JACQUELINE MEIER-JEWETTFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 801-2261
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 2DATE:
06/16/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Jacqueline Meier-JewettTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Deanna Villagrana met with licensee Jacqueline Meier-Jewett to deliver findings for a complaint received by the Department on 05/20/2021. Present were licensee, licensee's husband, adult daughter, granddaughter and one daycare child age two.

During the visit, LPA observed a 1A10BC fire extinguisher. LPA asked if that was the only extinguisher in the home. Licensee stated yes. LPA informed licensee it was the incorrect size and stated it needed to be 2A10BC or larger. Licensee's husband left during the visit and returned with a 3A40BC fire extinguisher.

An exit interview was conducted and a copy of this report and appeal rights were discussed and left with licensee Jacqueline, whose signature on this form confirms receipt of these documents. The following type B deficiency was cited on the attached page (809-D).

Notice of Site visit was issued and must be posted for 30 days.

SUPERVISORS NAME: Mary Segura
LICENSING EVALUATOR NAME: Deanna Villagrana
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2021
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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Document Has Been Signed on 06/16/2021 12:53 PM - It Cannot Be Edited


Created By: Deanna Villagrana On 06/16/2021 at 12:27 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
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: MEIER-JEWETT, JACQUELINE
FACILITY NUMBER: 354416074

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2021
Section Cited
CCR
102417(g)(1)

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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 Marshal.
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Licensee's husband left during the visit and returned with a 3A40BC fire extinguisher. Deficiency cleared today.
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This requirement was not met as evidenced by LPA observed a 1A10BC fire extinguisher. This poses a potential risk Health, Safety Personal Rights risk to children in care.
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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.
SUPERVISOR'S NAME:Mary Segura
LICENSING EVALUATOR NAME:Deanna Villagrana
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2021


LIC809 (FAS) - (06/04)
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