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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629600
Report Date: 05/01/2023
Date Signed: 05/01/2023 11:00:13 AM

Document Has Been Signed on 05/01/2023 11:00 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:JACQUECY, MYSTA FAMILY CHILD CAREFACILITY NUMBER:
376629600
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 2DATE:
05/01/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
07:40 AM
MET WITH:Mysta Jacquecy TIME COMPLETED:
10:00 AM
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On May 1st, 2023, at 7:40 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted a pre-licensing inspection with Applicant Mysta Jacquecy. The inspection’s purpose is to ensure that the home follows standards established in CCR, Title 22, Division 12, Chapter 3, for Family Child Care Homes. Applicant’s languages are Haitian Creole and Spanish. Link Operators 15548 and 16322 provided Haitian Creole language translation services. Present in the home were the Applicants and two (2) related children (under 10 years). Applicant states no animals/pets live in the home. This three (3) bedroom, two (2) bathroom, single floored house was toured and inspected.

The daycare schedule will be everyday 6 AM to 10 AM. The Applicant shall submit an updated application to the Licensing Department should the daycare operational schedule change.

The Applicant understands that they will need to notify the Department of any changes to the childcare areas and obtain departmental approval before use of any new childcare areas not previously licensed. Applicant will use the following areas for childcare: front yard, the fenced backyard, the living room, one (1) bathroom and one (1) bedroom. The off limits areas include the remaining bedrooms and bathroom. Access into the off limit bathroom is through an off limit bedroom. Off limit bedrooms have door locks. Cabinet locks are on kitchen cabinets. The fire extinguisher is rated 2A 10B: C. and is located in the kitchen. The smoke and carbon monoxide detectors meet requirements and are operational. Poisons, detergents, cleaning compounds and medications are secured inaccessible to children in care by placement in a high kitchen cabinet beyond a child’s reach. The Applicant indicated there are no firearms or other weapons in the home. Applicant reported that there are no bodies of water on the premises, and none were seen during the inspection.

The Applicant has a working telephone/cell phone. The Applicant shall notify licensing should their telephone number or email address ever change. Children’s toys and play equipment are available.

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/01/2023
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: JACQUECY, MYSTA FAMILY CHILD CARE
FACILITY NUMBER: 376629600
VISIT DATE: 05/01/2023
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The Applicant intends to conduct outdoor activities in the front and back yards. The Applicant acknowledge continuous, visual supervision shall be given whenever children are engaged in outdoor activities. The Applicant may occasionally transport the children in their own vehicle. The Applicant shall transport children in rear seats in appropriate child passenger restraint systems which meet applicable federal motor vehicle safety standards. The Applicant acknowledges that car seats shall only be used for transportation purposes and shall not be used for sleeping. The Applicant acknowledges children shall never be left unattended in the daycare vehicle. The Applicant stated they will maintain the service needs of the daycare vehicle to ensure safe transportation of children.

Applicant maintains documentation of proof of control of property for review by the Department. Immunization records per SB792 were reviewed and comply. Applicant was reminded that because the influenza vaccination is given yearly, they are to either receive the influenza vaccination on a yearly basis (and obtain written documentation confirming that vaccination) or substitute the yearly influenza vaccination with a yearly written declaration that they have declined the influenza vaccination. Applicant has completed the preventative health and lead poisoning prevention courses. The Applicant completed the Mandated Reporter training on 03/23/2023. Applicant acknowledges they will need to retake and obtain a new Mandated Reporter training course certificate once every two (2) years. Applicant’s pediatric CPR and First Aid certifications expire in March 2025. Applicant acknowledges they will need to update their pediatric First Aide and CPR certifications prior to their expiration dates.

The Applicant and adult residents in the home have criminal record clearances and/or exemptions on file. Applicant 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. Any minor upon their 18th birthday must be fingerprinted within 30 days. The Applicant was advised that any new/additional adults must be cleared prior to working or residing in 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.

LPA discussed the safe sleep regulations with the Applicant and discussed the Child Care Licensing Safe Sleep webpage at

SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: JACQUECY, MYSTA FAMILY CHILD CARE
FACILITY NUMBER: 376629600
VISIT DATE: 05/01/2023
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https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed applicant 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: http://www.ada.gov/childqanda.htm

LPA provided Applicant 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. The Applicant was also informed the following items are prohibited during day care operating hours: walkers, exersaucers, jumpers, inclined sleepers, and bouncy seats. Corporal punishment and smoking are not allowed in the day care.


Applicant and LPA reviewed the ratio/capacity worksheet. Applicant was reminded that the ratio also includes children, aged 10 years and younger, that also reside in the home. LPA discussed the maximum capacity for a small family childcare home: four infants only (infants mean any children under 24 months/2 years); or six children with no more than three infants; or, with landlord consent, eight children with no more than two infants, one child in kindergarten or elementary school and one child at least age six, including children under age 10 who live in the home. Applicant acknowledges their understanding of their legal ratios/capacity and agree to remain within those legal limits.

The Applicant state they are financially secure to operate a family childcare home for children and will comply with all regulations and laws governing family childcare homes.

Applicant was informed that the Department may conduct unannounced site visits to a licensed family day care home annually and as often as necessary to ensure compliance.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: JACQUECY, MYSTA FAMILY CHILD CARE
FACILITY NUMBER: 376629600
VISIT DATE: 05/01/2023
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Applicant was advised that any agent of the Licensing Department upon presentation of proper identification, may enter and inspect any place providing licensed personal care, supervision, and services at any time, with or without advance notice. The Applicant shall permit the Department to inspect the family childcare home, and to privately interview children, adults, or staff, to determine compliance with or to prevent violations of family childcare laws or regulations. Applicant was advised that the Department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation, if the Applicant refuses any agent of the licensing Department entry into the daycare or any part of the daycare.

LPA informed Applicant that the failure of Licensees to pay all applicable and accrued fees and/or civil penalties shall constitute grounds of forfeiture of the daycare license. Applicant understands the license will be closed if they do not pay all licensing fees by its deadline date.

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. 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. LPA enrolled Applicant’s email address into the Department’s email notification system; the email system awaits final email confirmation by the Applicant to complete the email notification enrollment process.


No corrections are needed. A small license is issued effective today 05/01/2023. The new license will be mailed to the Applicant when available. Exit interview conducted and report was reviewed with the Applicant Mysta Jacquecy.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4