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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 010216105
Report Date: 07/27/2022
Date Signed: 07/27/2022 12:21:42 PM


Document Has Been Signed on 07/27/2022 12:21 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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:JUBILADO, TERESAFACILITY NUMBER:
010216105
ADMINISTRATOR:JUBILADO, TERESAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 790-2724
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY:14CENSUS: 7DATE:
07/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Teresa JubiladoTIME COMPLETED:
12:25 PM
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On July 27th, 2022, @ 9:50am, Licensing Program Analyst (LPA) April Wright met with licensee Teresa Jubilado for an Unannounced Required 1 Year Inspection. LPA disclosed the purpose of the inspection and was granted entry into the home by the licensee. There were 6 children present, 4 preschool children and 2 infants and fingerprint cleared daughter/assistant Jessica Jubliado. Hours of operation are 7:00am - 5:30pm Monday through Friday.

LPA toured the home to conduct a health and safety inspection. The 2 story home was clean and orderly, with heating and ventilation for safety and comfort. The isolation area is the living room with use of pack n' plays which is away from other children in care when needed.
On limit areas include: are front/living room, day-care room, dining room, downstairs bathroom, and backyard.
Off-limits areas include: Entire second level of home, kitchen, shed and garage which are made inaccessible by closed and/or locked doors and visual supervision. There is a gate at the bottom of the stairs to prevent access to the upper level of the home as well as gates to prevent children from entering kitchen area. All food is cooked and provided by licensee. There are no pools, hot tubs or any other bodies of water present. LPA did not observe any hazardous materials or toxins accessible to children during today's inspection. There are ample age appropriate toys that are safe and in good condition. The licensee has first aid kit and earthquake preparedness backpack that is fully stocked and equipped.
The home has a fully charged 2A10BC fire extinguisher, three (3) dual working smoke detector/carbon monoxide, landline and mobile phones. There is a fire place in the Living room that is blocked and inaccessible to children in care. Per licensee there are no firearms in the home. The licensee is in compliance with the immunization laws which pertains to all childcare providers. See LIC809C for continuance.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: April WrightTELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: JUBILADO, TERESA
FACILITY NUMBER: 010216105
VISIT DATE: 07/27/2022
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LPA requested and reviewed the files of 6 children in care. The children's files contained, Parents rights, medical consent forms and identification and emergency contacts. The facility roster was review and copies were obtained. The licensee conducts fire and disaster drills once month and the last was conducted on 7-1-2022. The licensee has current CPR/First aid certificate which expires on 1-2-2024. Mandated Reporter training is current and was completed on 7/25/2022. Assistant Jessica has current CPR which expires on 8/23/2023 and Mandated Reporter training is current and was completed on 7/25/2022. The licensee is in ratio today. All required forms are posted and visible for public review.

Licensee was reminded that all assistants, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3000 per person, per incident.
Licensee was reminded that California Law requires licensed Family Child Care Home licensees to report unusual incidents or injuries to children in care to child's parents and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or electronic mail. LPA informed the Licensee that all forms can be downloaded at www.ccld.ca.gov The Licensee was also reminded that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

There are no deficiencies cited today. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee Teresa Jubilado.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: April WrightTELEPHONE: (510) 542-4257
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2022
LIC809 (FAS) - (06/04)
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