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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422571
Report Date: 05/23/2023
Date Signed: 05/23/2023 01:20:13 PM


Document Has Been Signed on 05/23/2023 01:20 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
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612



FACILITY NAME:LOW, JACQUELINEFACILITY NUMBER:
013422571
ADMINISTRATOR:LOW, JACQULINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 875-5649
CITY:SAN LEANDROSTATE: CAZIP CODE:
94578
CAPACITY:14CENSUS: DATE:
05/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee Jacqueline LowTIME COMPLETED:
01:30 PM
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On 05/23/2023 Licensing Program Analysts (LPAs) Andrew Elliot and Briana Plumboy arrived at the facility of Licensee Jacqueline Low at 9:00 am. LPAs were greeted by licensee at 9:05 am and began inspection of the physical plant at 9:07 am. At the time of inspection, Licensee Jacqueline Low and Assistant Ana Hernandez were present at the time on inspection, in addition to 3 infants and 6 pre-school aged children.
LPAs observed that the physical plant was clean and in good repair. The facility had working heating and air conditioning and was kept at a comfortable temperature. LPAs observed A fully charged 3A40BC Fire Extinguisher was kept at the ready in the facility, and that the facility had working smoke and Carbon Monoxide detectors. No bodies of water were present at the time of the inspection, nor where fire places or heated grates present. LPA observed that no poisons or cleaning detergents were present in on limits areas. As per interview with the licensee, no firearms were present at the time of inspection.
LPA began review of children's and staff's files at 10:00 am. LPA confirmed through file review that each child enrolled at the facility had an organized file, and that each staff member employed at the facility has a staff file organized. LPA confirmed through file review that each children's file contained an LIC 700, ID and Emergency info form, a LIC 627, Consent for Medical form, a LIC 995A, Parent's Rights form and immunization records. LPA confirmed through records review that each staff file contained an emergency information card, Criminal Record clearance, and that each employee had a current CPR/First Aid certificate and an up to date Mandated Reporter Training Certificate. LPA confirmed through file review that the facility have current emergency information cards, that an updated roster was present, that fire and disaster drills were conducted and documented within the last six months, and that signed copies of parent's rights were on file for each chid.

Continued on 809-C: Page 1 of 3.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Andrew ElliottTELEPHONE: (510) 363-5635
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2023
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LOW, JACQUELINE
FACILITY NUMBER: 013422571
VISIT DATE: 05/23/2023
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Incidental Medical Services (IMS) policy was discussed. 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, availableat: http://www.ada.gov/childqanda.htm Licensee was encouraged to frequently visit our website at ccld.ca.gov for licensing regulations and updates.

Notice of Site Visit A notice of site visit was given and must remain posted for 30 days. Appeal rights provided and discussed with the licensee.

Exit Interview Exit interview conducted and report was reviewed with the licensee Jacqueline Low. Appeal rights provided and discussed with the licensee.

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SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Andrew ElliottTELEPHONE: (510) 363-5635
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND SOUTH EAST, 1515 CLAY STREET STE 1102
OAKLAND, CA 94612
FACILITY NAME: LOW, JACQUELINE
FACILITY NUMBER: 013422571
VISIT DATE: 05/23/2023
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LICENSING POSTING: All REQUIRED forms are posted and visible for public review: Facility license, Notification of Parents’ Rights, Earthquake Preparedness, Emergency Disaster Plan. Licensee was reminded that exersaucers, baby walkers, bouncers, jumpers, and similar items are not allowed, and that smoking is prohibited in the home during day care hours.

Safe Sleep LPA discussed the safe sleep regulations with licensee Jacqueline Low 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 MS. Low 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.

Continued on 809-C: Page 2 of 3.

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 421-1324
LICENSING EVALUATOR NAME: Andrew ElliottTELEPHONE: (510) 363-5635
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6