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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700046
Report Date: 08/03/2021
Date Signed: 08/03/2021 01:15:03 PM

Document Has Been Signed on 08/03/2021 01:15 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:JENSEN FAMILY CHILD CAREFACILITY NUMBER:
367700046
ADMINISTRATOR:JENSEN, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(951) 963-6114
CITY:BARSTOWSTATE: CAZIP CODE:
92311
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 10DATE:
08/03/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Maria JensenTIME COMPLETED:
12:30 PM
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On 08-03-21, Licensing Program Analyst (LPA) Lady King-Lewis arrived a the facility to conduct a case management visit. The purpose of the case management visit was to follow-up on a self reported Unusual Incident Report submitted by the facility on 07-30-21.

Description of incident: On 07/30/21, Child #1 sustained scratches on both eyes and forearm while climbing on a play structure that broke, causing the above injuries. Licensee treated the scratches with First aid and parent was notified and medical attention was sought, no stitches were needed.

During inspection, LPA interviewed licensee, Children in day care, injured child mother and received copy of the day care roster. LPA also reviewed photos taken by the licensee of child 1 injury.

Based on observations and interviews obtained It is determined that the play equipment was not in good repair resulting in a day care child sustaining injuries to face and arm. Licensee removed the play structure prior to this inspection.



This facility is being cited Type B deficiencies. According to the California Code Title 22 Regulation.

See Facility Evaluation Report LIC 809D for deficiencies.

An exit interview was conducted, Appeal Rights provided, a Notice of Site Visit given and informed to be posted for 30 days.
SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2021
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 08/03/2021 01:15 PM - It Cannot Be Edited


Created By: Lady King On 08/03/2021 at 12:38 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JENSEN FAMILY CHILD CARE
FACILITY NUMBER: 367700046

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2021
Section Cited
CCR
102417(d)

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102417 Operation of a Family Child Care Home: The home shall provide safe toys, play equipment and materials. This requirement was not met by evidence the play structure broke when a child climb up on the play structure.
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Licensee removed the play structure from the facility. Licensee reminded to continue to inspect play equipment for safety each day prior to children playing on the structure
Type B
08/10/2021
Section Cited
CCR
102423(a)(2)

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102423 Personal Rights (a) (2) To receive safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement was not met as evidence by: child, injured eye area and forearm when licensee play strructure broke while child was climbing on the play structure.
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Licensee shall submit written statement stating she understand the children personal Rights and play equipment will be inspected daily for safety prior to children being allowed to play on the play equipment..

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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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2021


LIC809 (FAS) - (06/04)
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