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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700002
Report Date: 06/12/2023
Date Signed: 10/04/2023 10:33:51 AM

Document Has Been Signed on 10/04/2023 10:33 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:JACKSON FAMILY CHILD CAREFACILITY NUMBER:
367700002
ADMINISTRATOR:OTECHIA JACKSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 246-4174
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
06/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Otechia JacksonTIME COMPLETED:
04:00 PM
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The report dated 06/12/2023 is being amended.....On 6/12/2023, Licensing Program Analyst (LPA) Carol Heath conducted an unannounced Required 1-Year inspection at the Jackson Family Child Care. Upon arrival, the LPA met with the licensee, Otechia Jackson, who guided the LPA on a tour of the facility. Individuals that reside in the home include 1 adult (the licensee) and 3 children (16,14 and 11 years old sons).
This is a large family childcare facility. The hours of operation are Monday through Saturday. During the inspection, LPA observed 11 childcare children (5 school-age and 6 preschools) with Licensee and her assistant #1. Per CCIB, assistant #1 is eligible and clearance to provide care and supervision to children. Per the Licensing Information System, annual facility fees were current. Incidental Medical Services (IMS) were discussed. Per the licensee, she does not have children who need IMS at this time.
The home is set up as follows: This is a single-story home That consists of 3 bedrooms, 2 bathrooms, a kitchen, a dining area, a family room, a living room, a garage, and a backyard. The home was inspected for safety, comfort, cleanliness, telephone service, central air, and heat and ventilation. The house has central heating and air conditioning. All windows have screens free of cracks, bugs, and debris.
Main Area: Main care is provided in the Family room and dining area. Children use the bathroom across from the bedroom in the hallway. Children have access to the kitchen and backyard.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2023
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 367700002
VISIT DATE: 06/12/2023
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· Family Room and Dining room: In the playroom (family room), the designated playroom, LPA observed age-appropriate toys and furniture for the children. There are games and books on the premises of this facility. The carpets and other materials were observed to be in good condition.
· Children's bathroom: The bathroom was the tour. The bathroom was clean, sanitized, and in good repair. The toilet was inspected, and the sink/toilet is in operable condition. The toilet and faucets are clean, safe, and operable. The bathroom was observed to be free and clear of hazardous items.
· Backyard (off-limit): The backyard was inspected; the children use the outdoor backyard for outside play. However, the gate and several materials need to repair. The backyard is gated all around. There is a grass and concrete area for active play.
· Off-limit: The areas include all bedrooms (key locked), laundry room (key locked), and garage (key locked). Kitchen/Dining Room: The kitchen was inspected to ensure dangerous items were inaccessible to children (Safety latches). All sharp utensils, poisons, and medications are unavailable to children in the kitchen, with child safety latches on cabinet doors and drawers. Sharp knives are kept in a butcher block in the gated kitchen.
Other:
· AC/Heating Unit / Swamp Cooler unit was observed. The AC/Heating Unit is located on the right side of the home and is inaccessible to children via barrels blocking access to the AC unit. However, the gate will need to be secured.
· Bodies of water: Pre the licensee, there were no bodies of water in the home. There is a decorative water fountain that has no water.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 367700002
VISIT DATE: 06/12/2023
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· Electrical outlets: All unused electrical outlets are plugged in and made inaccessible to children.
· Food: The licensee is enrolled in Food program. The licensee will provide Breakfast, lunch, and snacks.
· Fire extinguisher (2A10BC): LPA observed a required fire extinguisher (2A10BC) reading in Green and located in the classroom, inaccessible to children. It meets standards established by the State Fire Marshall.
· Fireplace: The fireplace was observed in the living room and is screened to make it inaccessible to the children. There is a shelf in front of the fireplace.
· Hanging window blind cords: The cords are inaccessible to children.
· Isolation area (Illness): Per the licensee, if the child shows signs of illness, they will be separated from other children.
· Medications and cleaning solutions: Detergents/cleaning compounds are in the off-limit area, inaccessible to the children. Medications are in the off-limits bedroom.
· Napping: Children will nap in designated areas with adult supervision. LPA observed 10 mats in the closet.
· Overnight Care: According to the licensee does not provide overnight care.
· Pets: No pet
· Phone service: There is a working landline or cell phone
· Smoke Detectors and Carbon Monoxide: The smoke detectors and carbon monoxide devices tested operable.
· The First Aid kit is in the classroom, inaccessible to children. The First Aid Kit was observed to be complete with supplies and a first aid manual.
· Transportation: The licensee does provide transportation for children. The licensee has a valid California driver's license, valid vehicle insurance, and vehicle registration.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 367700002
VISIT DATE: 06/12/2023
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· Weapons or Firearms: Per the licensee, there are No Firearms at the facility at this time. LPA does not observe any firearms.
Documentation:
· Child files: LPA observed that 5 children's files contained all required licensing documents.
· CPR/First Aid: LPA observed licensee has current Pediatric CPR and First Aid Training with an expiration date (of 12/2023).
· Fire Drill and Disaster Drill: Per the licensee, fire and disaster drills are conducted every 6 months; the last drill was documented and performed on 2/2023
· Immunization: The licensee and her assistant have the required immunizations (MMR and DTaP). The licensee and her assistant provided a written statement declining the influenza vaccination.
· Infant Sleeping Plan (LIC 9227) and Sleeping Log: LPA shared the information with the licensee. Per the licensee, NO infant (0-12 months) is enrolled in the facility.
· The licensee (does not) post all required information
· Mandated Reporter Training: The licensee has completed and renewed the online mandated reporter training at www.mandatedreporterca.com on 2/13/23
· Staff Personnel File: LPA observed 1 staff information. The assistant will need to have mandated reporter training and CPR/First Aid
The following information was discussed with the licensee:
üMandatory Forms for the children's files and provider's files.
üThe licensee is reminded that 100% supervision is required for children at all times.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 367700002
VISIT DATE: 06/12/2023
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üCapacity requirements, Roster requirements, and Documentation requirements for disaster drills (fire and earthquake).
üLicensee was made aware that it is their responsibility to know the regulations and anyone who assists in providing care. Licensee was advised that the inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must always have the facility's phone number; if the phone number is changed, licensing must be notified.
üLicensee was advised of the requirement to report unusual incidents and injuries to the parent/guardian and Licensing within the time frame specified by the regulation and on the form LIC624B
üThe licensee was informed of the responsibility to report suspected Child Abuse by calling the Child Abuse Hotline at 1-800-540-4000. Also, call the CCL office and follow up with a written Unusual Incident/Injury Report (LIC 624B).
üCriminal Record Statement: The licensee [or facility representative] was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption or transfer their existing support or exemption prior to the 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.
üSafe Sleep: LPA discussed the safe sleep regulations with the licensee [or facility representative] 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.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 367700002
VISIT DATE: 06/12/2023
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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.
üA baby walker shall not be allowed on the premises of a family child care home in accordance with Health and Safety code sections 1596.848(b) and (c). State law prohibits baby walkers, bouncy seats, exersaucer, and other items that fall into that category.
üNotice of Site Visit: A notice of site visit was given and must remain posted for 30 days.
üPosting Requirements: Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
üThe regulation prohibits the smoking of tobacco in a private residence that is licensed as a family childcare home and in those areas of the family day care home where children are present (24/7 ban).
üLicensee was advised to visit the CCL website (www.ccld.ca.gov) to obtain updates on courses and updates/changes to the regulations.
nOur Quarterly updates come out every 3 months. They are also now in Spanish. Please log in to the CCLD website, or you can email our advocates to have the quarterly updates sent directly to your email. Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
üThe Duty Worker is available for questions Monday through Friday at (661) 202-3318 from 8:00 a.m. - 5:00 p.m.
üA copy of the Safe Sleep Proposed Regulations was provided to the licensee.
Deficiencies cited: (See LIC 809D). The following Type A deficiencies are being cited in accordance with Title 22 of the California Code of Regulations and Health & Safety codes.
An exit Interview was conducted, and a copy of this Report and a Notice of Site visit were provided to the licensee.
SUPERVISORS NAME: Claretta Yates
LICENSING EVALUATOR NAME: Carol Heath
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/05/2023 10:00 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/30/2023 11:39 AM


Created By: Carol Heath On 06/12/2023 at 03:16 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
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 367700002

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
102370(d)(1)
Criminal Record Clearance
(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, interview, and record review, the licensee failed to comply with the section cited above and allowed individual #1 to provide care and supervision to children without a criminal record clearance for more than 5 days, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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According to the licensee, the individual #1 did start with his exemption process. However, the assistant and the licensee did not follow through the process. The licensee agreed to send the assistant home during the inspection and the assistant will not return until his livescan is clearned. The licensee will mantated her ratio with her son (16 years old). The son will not be alone with the childcare children.
Section Cited
Deficient Practice Statement
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POC Due Date:
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.
SUPERVISOR'S NAME:Claretta Yates
LICENSING EVALUATOR NAME:Carol Heath
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2023


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