<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444406040
Report Date: 09/13/2021
Date Signed: 09/13/2021 12:08:59 PM

Document Has Been Signed on 09/13/2021 12:08 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, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:JACKSON, ADINAFACILITY NUMBER:
444406040
ADMINISTRATOR:JACKSON, ADINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(831) 338-3873
CITY:BOULDER CREEKSTATE: CAZIP CODE:
95006
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Adina JacksonTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Goodell met with licensee, Adina Jackson, for the purpose of an Unannounced Annual Random Inspection. Hours of operation are Monday- Friday, 7:00am- 5:30pm. During inspection LPA, observed 1 child present with licensee. All individuals subject to criminal background review have obtained a criminal record clearance.

Inspection was conducted in all areas accessible to children. Off-limits areas include entire upstairs, garage, husband's workshop located in yard and carport. LPA verified phone number and email are current. LPA also observed a 3A40BC fire extinguisher, smoke and carbon monoxide detectors. No weapons or bodies of water in the home.. LPA observed cleaning compounds, medication and knives are stored inaccessible to children. Licensee acknowledged that 100% supervision is required in unfenced area. Child records and staff files were reviewed. LPA also observed fire drill log and children roster maintained. Preventative health training, current pediatric CPR and first aid certification was verified and expires 8/2023 The Effects of Lead Exposure brochure posted. Licensee was encouraged to visit the Department website at WWW.CDSS.CA.GOV for child care updates, forms, self-assessment guides, legislation and regulation information. PIN 21-08-CCP and COVID-19 UPDATE Guidance: Child Care Programs and Providers were discussed.

No deficiency cited. LPA reviewed report with the licensee and provided copies. An exist interview was conducted. The Notice of Site Visit issued and must remain posted for 30 days.
SUPERVISORS NAME: Diana Stephenson
LICENSING EVALUATOR NAME: Kristal Goodell
LICENSING EVALUATOR SIGNATURE: DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1