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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629600
Report Date: 02/12/2024
Date Signed: 02/12/2024 01:31:57 PM

Document Has Been Signed on 02/12/2024 01:31 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, 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:
02/12/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Mysta JacquecyTIME COMPLETED:
01:00 PM
NARRATIVE
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On February 12, 2024, at 10:25 AM, Licensing Program Analyst (LPA) Jo Ann Legaspi conducted an unannounced Annual Required Inspection and met with the Licensee Mysta Jacquecy. LPA disclosed the purpose of the inspection and was granted facility entry by the Licensee. Focus Language International operators 83999307 and 83994518 provided Haitian Creole language translation services. Only the Licensee and her two children were present in the facility during this inspection. This facility is a three (3) bedroom, two (2) bathroom house. Licensee accompanied LPA during this inspection. The following areas used for childcare are: front yard, the fenced backyard, the living room, one (1) bathroom and one (1) bedroom. The off-limit areas are the kitchen, remaining bedrooms, and remaining bathroom. Cabinet locks are on kitchen cabinets. Access into the off-limit bathroom is through an off-limit bedroom. Off limit bedrooms have door locks.

The fire extinguisher, smoke detector, and carbon monoxide detector met requirements. Hazardous items were observed inaccessible to children during this inspection. The Licensee has available toys, play equipment and materials. Licensee states children play in the front and fenced backyard. The licensee was reminded that continuous supervision is to be given to children whenever engaged in outdoor activities. No bodies of water were observed on the premises during the inspection. Licensee stated there are no weapons in the home.

Licensee’s First Aid and CPR certifications expire in March 2025. Licensee was reminded to retake the pediatric First Aide and CPR course and obtain its recertification card before March 2025. Licensee has required immunizations. Mandated Reporter Training was completed on 03/23/2023. Licensee was reminded to retake the Mandated Report Training course and obtain its training completion certificate by 03/23/2025. The facility roster is maintained and was reviewed. The Licensee states they cannot recall whether a disaster drill has been conducted.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2024
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 02/12/2024 01:31 PM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 02/12/2024 at 11:19 AM
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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: JACQUECY, MYSTA FAMILY CHILD CARE
FACILITY NUMBER: 376629600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and translated interview with the licensee, the licensee did not comply with the section cited above in that neither a fire nor disaster drill has been conducted and documented once every six months, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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LPA provided Licensee with a blank Safety Drill Log. Licensee said she will conduct a safety drill and document on the provided Safety Drill Log before emailing the completed form to LPA no later than 03/0/2024.
Type B
Section Cited
CCR
102425(j)(1)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall physically check on the infant every 15 minutes.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and file review, the licensee did not comply with the section cited above in 1 out of 1 infants which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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LPA provided Licensee with a blank Safe Sleep Infant Log, Spanish Version. Licensee said she will document the daycare infant's sleep and email LPA the completed form no later than 03/08/2024.
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2024 01:31 PM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 02/12/2024 at 11:19 AM
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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: JACQUECY, MYSTA FAMILY CHILD CARE
FACILITY NUMBER: 376629600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviews, the licensee did not comply with the section cited above in 3 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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LPA provided Licensee with a blank LIC 700 Emergency Information form, Spanish version. Licensee said she will have the parents complete this form and she will email LPA a copy of the completed forms no later than 03/08/2024.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 3 persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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LPA provided Licensee with a blank LIC 700 Emergency Information form, Spanish version. Licensee said she will have the parents complete this form and she will email LPA a copy of the completed forms no later than 03/08/2024.
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/12/2024 01:31 PM - It Cannot Be Edited


Created By: JoAnn R Legaspi On 02/12/2024 at 11:19 AM
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
, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108

FACILITY NAME: JACQUECY, MYSTA FAMILY CHILD CARE
FACILITY NUMBER: 376629600

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviews, the licensee did not comply with the section cited above in 3 out of 3 total count persons/identifiers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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LPA provided Licensee with blank LIC 282 forms, Spanish version. Licensee said she will have the parents complete, date and sign before emailing LPA copies of these completed forms no later than 03/082/2024.
Type B
Section Cited
CCR
102425(j)(2)(D)
Infant Safe Sleep
Documentation shall be maintained in the infant’s file and be available to the Department for review. Documentation shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record reviews, the licensee did not comply with the section cited above in 1 out of 1 infants/identifiers which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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LPA provided Licensee with a blank Infant Safe Sleep Log, Spanish version. Licensee said she will document the sleeping infant every 15 minutes upon this form and provide a copy of the completed form to LPA no later than 03/08/2024.
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:Tulam Vu
LICENSING EVALUATOR NAME:JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024


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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: 02/12/2024
NARRATIVE
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Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

On this date, 01/12/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. During the exit interview, the Licensee Mysta Jacquecy, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA discussed the safe sleep regulations with licensee 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 licensee 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 provided Licensee with Provider Information Notice (PIN) 20-24-CCP, a blank LIC 9227 “Individual Infant Sleeping Plan” form and two (2) examples of safe sleep logs.

LPA reviewed with licensee 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. Entrance Checklist was provided to the licensee. LPA reminded Licensee of the following: Report suspected child abuse and neglect, maintain children’s records according to regulation, post all required forms, and ensure that all adults residing or working in the home have criminal background clearances or exemptions. Licensee was reminded that
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
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: 02/12/2024
NARRATIVE
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corporal punishment, smoking, exersaucers, bouncy seats, walkers, and jumpers and/or similar equipment are not allowed in daycare.

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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

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 platforms. 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.

Deficiencies were observed as per California Code of Regulations, (Title 22, Division 12 & Chapter 3), and is being cited on the attached LIC 809-D. A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days. Exit interview conducted and report was reviewed with the Licensee Mysta Jacquecy.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.
SUPERVISORS NAME: Tulam Vu
LICENSING EVALUATOR NAME: JoAnn R Legaspi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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