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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629838
Report Date: 03/05/2024
Date Signed: 03/05/2024 06:17:24 PM

Document Has Been Signed on 03/05/2024 06:17 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:DECILMYS, JACOB FAMILY CHILD CAREFACILITY NUMBER:
376629838
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jacob DecilmysTIME COMPLETED:
12:45 PM
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On 03/05/24 at 11:30 a.m., Licensing Program Analyst (LPA) Cindy Meier conducted an announced Pre-licensing inspection with applicant, Jacob Decilmys. The purpose of the inspection is to ensure the home is in compliance with standards established in CCR, Title 22, Division 12, Chapter 3, for Family Child Care Homes. This one story, four-bedroom, two bath home was toured and inspected. Present during the inspection were applicant, adult resident A1, A2, A3, and A4, all criminal record cleared. The LPA used Focus Language during the inspection which provided translation for the applicant.

Upon touring the home LPA noticed access to another building behind the applicant’s residence. The applicant stated the residence is separate with the address 4539 Imperial Avenue, San Diego, CA 92113. The applicant stated the residents of the home at 4539 park in the front driveway of his house and walk on the walkway to their home. Applicant stated they are not related. LPA did not observe any divider or fence separating the two properties and children would have access to walk to the back property.

LPA stated to applicant a license would not be issued until the following items are researched and completed:
-verification from owner of home and San Diego County assessors the back property at 4539 is registered as a separate residence
-a fence is installed to separate the two residences
-hazardous debris from front yard is removed
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2024
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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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: DECILMYS, JACOB FAMILY CHILD CARE
FACILITY NUMBER: 376629838
VISIT DATE: 03/05/2024
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LPA will verify if residents in back home need to be fingerprinted cleared due to the access.

A Regular Small Family Child Care Home license will not be issued at his time. LPA Meier explained inspection report to applicant, applicant stated she understood. Exit interview conducted and report was reviewed with the applicant, Jacob Decilmys.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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