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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629838
Report Date: 03/15/2024
Date Signed: 03/16/2024 05:02:35 PM

Document Has Been Signed on 03/16/2024 05:02 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:
03/15/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jacob DecilmysTIME COMPLETED:
10:30 AM
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On 3/15/24 at 9:00 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-bathroom home was toured and inspected. The hours of operation are Monday through Sunday, 23 hours. The LPA used Focus Language during the inspection which provided translation for the applicant.

Applicant will utilize the following areas for childcare: living room and bathroom. Off Limit areas include: bedrooms, #1, #2, #3, #4, kitchen, and bathroom #2. Off limit areas are inaccessible to children by use of safety gates, safety latches or doorknob covers. Applicant will utilize front patio for outdoor activities or take children to the park. LPA informed applicant to ensure children are supervised at all times during outdoor activities.
The fire extinguisher is rated 2A:10B:C and is located in the hallway, smoke and carbon monoxide detectors meet requirements and are operational. Detergents, cleaning compounds, and medicines are inaccessible to children in care and poisons are to be locked away. LPA did not observe any poisons during the inspection. There is no fireplace on the premises. Applicant stated there is no pool or bodies of water on the premises. LPA did not observe any pool or bodies of water during inspection. Children’s toys and play equipment are available. The applicant has a working cell phone.

Applicant stated there are no firearms, other weapons, or ammunition in the home.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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: 03/15/2024
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The applicant provided proof of control of property. Because the applicant, rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149) and is approved to care for up to 8 children.

Applicant’s Mandated Reporter AB1207 training expires on 2/1/2026. Applicant completed 8 hours of preventative health which included nutrition and lead training on 12/7/2023. Pediatric CPR and First Aid certifications expire on 12/23/2025. Immunization records per SB792 were reviewed and met regulations. Required documents are posted.
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, 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.

LPA advised applicant that prior to making alterations or additions to the home or grounds, the applicant shall notify the Department of the proposed change. Applicant states 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 does not plan on providing Incidental Medical Services (IMS) to clients at this time. IMS policy was discussed. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. 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, available at: http://www.ada.gov/childqanda.htm.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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: DECILMYS, JACOB FAMILY CHILD CARE
FACILITY NUMBER: 376629838
VISIT DATE: 03/15/2024
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The New Provider Resource Packet was reviewed with the applicant including information on the following: PIN20-24-CCP Safe Sleep Regulations, lead exposure, SIDS, shaken baby, child abuse reporting, community resources, children’s records, facility records, required postings, immunization's, unusual incident report, facility roster, car seat law, visual for ratio/capacity, fire/disaster drill log. Applicant was also informed the following items are prohibited during day care operating hours (walkers, exersaucers, jumpers and bouncy seats). Corporal punishment and smoking are not allowed in the day care.

LPA discussed the safe sleep regulations with applicant 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 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.

LPA reviewed with 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. Entrance Checklist was provided to the applicant.

LPA discussed the maximum capacity for a small family childcare home: four infants only (infants mean any children under 24 months); 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.

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.
SUPERVISORS NAME: Jason Garay
LICENSING EVALUATOR NAME: Cindy Meier
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
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: DECILMYS, JACOB FAMILY CHILD CARE
FACILITY NUMBER: 376629838
VISIT DATE: 03/15/2024
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On this date, 3/4/2024, 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.

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 San Diego Regional Office Duty Line was provided: (619) 767-2248.

Southern California Child Care Advocate information was provided, and applicant was encouraged to subscribe through the CCLD website in order to be placed on an email list for updated regulation information. Advocate information was provided: (714) 703-2800 or childcareadvocatesprogram@dss.ca.gov.

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

A Regular Small Family Child Care Home license may be issued upon final file review. 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: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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