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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629600
Report Date: 06/03/2025
Date Signed: 06/04/2025 07:40:43 AM

Document Has Been Signed on 06/04/2025 07:40 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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:JACQUECY, MYSTA FAMILY CHILD CAREFACILITY NUMBER:
376629600
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: DATE:
06/03/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:25 AM
MET WITH:Mysta JacquecyTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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On 6/3/2025, at 8:25 a.m., Licensing Program Analyst (LPA), Victoria Hernandez conducted an unannounced change of capacity inspection and met with Licensee, Mysta Jacquecy. LPA disclosed the purpose of the inspection and was led on a tour of the facility indoors and outdoors. This facility is a one story, three-bedroom, two-bathroom house. The following areas are used for childcare: living room/dinning room, bathroom #2, bedroom #3, and back yard. Off limits areas include: bedrooms #1, and #2, and bathroom #1 which are made inaccessible through the use of safety gates, locks and doorknob covers.

Hours of operation hours are Monday – Friday, 6:00 a.m. to 10:00 p.m. There was three (3) of licensee own children present during the inspection. The LPA used Focus Language during the inspection which provided translation for the licensee. Licensee primary language is Haitian Creole.

The fire extinguisher, smoke detector and carbon monoxide detector met requirements. LPA informed licensee poisons shall be placed in a storage area and locked. LPA observed toys and materials available for children’s use. The home has a fenced backyard available for outdoor activities. LPA informed licensee to ensure children are supervised at all times during outdoor activities. There is no fireplace on the premises. Licensee stated there are no bodies of water and LPA did not observe any bodies of water during the inspection. Licensee stated there are no firearms, other weapons, or ammunition in the home.

A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse clearances or exemptions. LPA was not able to review children’s files. Children’s files were not reviewed please see LIC 809 D.
NAME OF LICENSING PROGRAM MANAGER: Jason Garay
NAME OF LICENSING PROGRAM ANALYST: Victoria Hernandez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/04/2025 07:40 AM - It Cannot Be Edited


Created By: Victoria Hernandez On 06/03/2025 at 09:42 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: 06/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102419(b)
Admission Procedures and Authorized Representatives Rights
(b) The licensee shall post the PUB 394 (8/02), Family Child Care Home Notification of Parents’ Rights Poster in a prominent, publicly accessible area in the family child care home at all times children are in care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in not posting PUB 394 and license which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2025
Plan of Correction
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LPA provided a copy of PUB 394 and license to be posted immediately
Type A
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 interview and record review, the licensee did not comply with the section cited above in not having 0/3 childrens file ready to view which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2025
Plan of Correction
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LPA provided copies of childrens file to be completed by 6/4/25 and licensee will be provided complete childrens file to the SDRO on 6/6/25
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Jason Garay
NAME OF LICENSING PROGRAM MANAGER:
Victoria Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2025


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/04/2025 07:40 AM - It Cannot Be Edited


Created By: Victoria Hernandez On 06/03/2025 at 09:42 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: 06/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not having a current facility roster which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2025
Plan of Correction
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LPA provided a copy of roster to be completed by 6/4/25 and licensee will be provided complete childrens roster to the SDRO on 6/6/25
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.
Jason Garay
NAME OF LICENSING PROGRAM MANAGER:
Victoria Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/04/2025 07:40 AM - It Cannot Be Edited


Created By: Victoria Hernandez On 06/03/2025 at 09:42 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: 06/03/2025

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: 06/06/2025
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 06/06/25.
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.
Jason Garay
NAME OF LICENSING PROGRAM MANAGER:
Victoria Hernandez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2025


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
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: JACQUECY, MYSTA FAMILY CHILD CARE
FACILITY NUMBER: 376629600
VISIT DATE: 06/03/2025
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.

Licensee’s Mandated Reporter AB1207 training expires 05/2027. Pediatric CPR and First Aid certifications expire on 04/2027. Licensee has required immunizations, per file review. Facility roster was not maintained and could not be reviewed. The licensee has not conducted fire and disaster drills. Required documents were not posted please see LIC 809-D.

This facility provides Incidental Medical Services – IMS. LPA reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see PIN 22-02-CCP. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514- 0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA are available at: https://www.ada.gov/resources/child-care-centers/.

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 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 applicant.
NAME OF LICENSING PROGRAM MANAGER: Jason Garay
NAME OF LICENSING PROGRAM ANALYST: Victoria Hernandez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC809 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO CC RO, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: JACQUECY, MYSTA FAMILY CHILD CARE
FACILITY NUMBER: 376629600
VISIT DATE: 06/03/2025
NARRATIVE
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LPA and licensee discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov. LPA discussed and provided Licensee with the following: childcare advocates email address: childcareadvocatesprogram@dss.ca.gov. In addition, for general questions or questions licensing requirements contact the Child Care Licensing Duty Line at (619) 767-2248.


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.

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.

Per California Code of Regulations, (Title 22, division 12 & Chapter 3) three (3) Type A citations, one (1) Type B is being cited on the attached LIC 809-D.)

LPA Victoria Hernandez informed Licensee, Mysta Jacquecy that this report dated 6/14/22 document(s) (2) Type A citation(s) which shall be posted for 30 consecutive days as there is immediate risk(s) to the health, safety, or personal rights of children in care.

Also, LPA Victoria Hernandez informed the Licensee, Mysta Jacquecy to provide a copy of this licensing report dated 6/3/25 that documents Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee, Mysta Jacquecy.
NAME OF LICENSING PROGRAM MANAGER: Jason Garay
NAME OF LICENSING PROGRAM ANALYST: Victoria Hernandez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC809 (FAS) - (06/04)
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