013422571-7-3-2019-52-CC-MGUT-BDQT9R-20190703143221

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 013422571
Report Date: 07/03/2019
Date Signed: 07/03/2019 02:32:35 PM

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:	LOW, JACQUELINE		FACILITY NUMBER:	013422571
ADMINISTRATOR:			FACILITY TYPE:	810
ADDRESS:			TELEPHONE:
CITY:		STATE:	ZIP CODE:
CAPACITY:	8	CENSUS: 0	DATE:	07/03/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jacqueline Low		TIME COMPLETED:	03:00 PM

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On 07/03/2019, Licensing Program Analysts (LPA) Guirit and Chew met with licensee, Jacqueline Low for an unannounced site inspection and capacity increase. Present for this visit was fingerprint cleared licensee. The home was toured to conduct a Health and Safety Inspection. During today's inspection, she is operating as a small FCCH with no children present.

The home is single story. The home consists of a living room, dining room, kitchen, family room, 4 bedrooms, 3 bathrooms, attached converted garage/playroom, laundry room/bathroom, backyard, and front yard. The off limits areas are the kitchen, family room, the 4 bedrooms, front yard, and 3 bathrooms which are inaccessible by closed doors, gate barricades, and visual supervision at all times. The on limit areas are the living room, dining room, converted garage, laundry/bathroom, backyard. The home is clean with heating and ventilation for safety and comfort. The isolation area will be in the living room. There is a fully fenced outdoor patio/play area and is free from defects or dangerous conditions. There are no pools, hot tubs or any other bodies of water during today's inspection. All hazardous materials and toxins are stored and inaccessible to children in care during today's inspection. There are ample age appropriate toys that appear to be safe and in good condition. The home has a fully charged 2A10BC fire extinguisher, fire alarm per San Leandro Fire Dept., working smoke detector, working carbon monoxide detector, and working telephone. There are no fireplaces or wall heaters. The fire dept. inspection and review was reviewed and was approved on 05/28/19. Per licensee, there are no firearms in the home during today's inspection.

A copy of the child roster was obtained and reviewed. Licensee has a record of conducting and documenting fire and disaster drills at least once every six months with the last drill on 5/22/2019. All required forms are posted and visible for public review upon entry. Licensee has completed the Mandated Reporter Training which expires 07/2020 and CPR and First Aid which expires 11/2019. A review of the Facility Personnel Report Summary indicates that all facility staff or other individuals who required caregiver background checks have received criminal record and child abuse index clearance or exemptions. See 809-C for continuance.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

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: LOW, JACQUELINE	FACILITY NUMBER: 013422571
	VISIT DATE: 07/03/2019

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Licensee is 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 of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov .http://www.myccl.gov/

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (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

There are no deficiencies cited today. This report shall remain on file for 3 years. A notice of site visit was given and must remain posted for 30 days. Exit interview conducted and appeal rights provided. Updated license will be mailed upon manager approval.

SUPERVISOR'S NAME: Sherelle Johnson	TELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Melissa Guirit	TELEPHONE: (510) 622-2624
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2019

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2019

LIC809 (FAS) - (06/04)

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