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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013422743
Report Date: 07/29/2019
Date Signed: 07/29/2019 05:10:12 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:JORDAN, TARSHAFACILITY NUMBER:
013422743
ADMINISTRATOR:JORDAN, TARSHAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 938-1987
CITY:OAKLANDSTATE: CAZIP CODE:
94608
CAPACITY:14CENSUS: 11DATE:
07/29/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:28 PM
MET WITH:Tarsha JordanTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst Caroline Colson met with Tarsha Jordan, her mother, Marsha Jordan, her assistants, Danielle Vigil and Miriam Ogden for an unannounced random annual inspection at 2:28 PM. One child's record was reviewed by the LPA and the licensee on 7/29/19 at 4:43 PM. C1 has immunization records but not on the California School Immunization Form. There are no additional records available. There are four (4) infants and seven (7) preschool children. The home was toured to conduct a health and safety inspection.

The home is a one story home. The home consists of a living room, dinning, kitchen with an eating area, 3 bedrooms, 1 bathroom, 1 laundry room, fenced back yard, storage unit and a drive way. Two bedrooms, kitchen, laundry room, storage unit and driveway are the off limit areas. The master bedroom will be used as an isolation area. There is a 2A10BC fire extinguisher, working smoke and carbon monoxide detectors. Mrs. Jordan states that there are no firearms in the home. Her pediatric CPR and First Aid certificates expire on September 30, 2020. There is a first aid kit available. She has no pets.

This facility is not providing Incidental Medical Services-IMS at this time. LPA discussed IMS services and the requirement to create a plan of operation. Specifics on the plan can be found in the family child care home evaluator manual (FCCH EM) Policy 102417.

Please LIC 809 C for additional information
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
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 3
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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JORDAN, TARSHA
FACILITY NUMBER: 013422743
VISIT DATE: 07/29/2019
NARRATIVE
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REMINDERS/RESOURCES
· Criminal Background Clearance: All assistants, volunteers, frequent adult visitors (adults are individuals 18 years of age or older) must be fingerprint cleared and associated to the facility prior to be in the presence of children in care. Failure to comply, requires an immediate civil penalty of $100 to $3000 per person, per incident.

· CCLD Complaint Hotline, 1-844-LET-US-NO (1-844-538-8766) email: LetUsNo@dss.ca.gov

· NEW LAW: Safe Sleep Regulations: http://www.cdss.ca.gov/inforesources/Child-Care-Licensing/Public-Information-and-Resources/Safe-Sleep

· Licensees and all staff are Mandated Reporters and are required to report to CCLD any suspected child abuse.

CCLD website address for obtaining licensing forms, training videos and other provider resources can be obtained at www.ccld.ca.gov

· Licensees may register to receive child care updates: www.myccl.ca.gov

Analyst reviewed required documents for all children's records and obtaining assistance from our technical support department. In addition, diaper changing procedures were discussed.

Mandated Reporter Training Certificates will be sent to our office in 30 days.

Please See LIC 809 D for deficiencies
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JORDAN, TARSHA
FACILITY NUMBER: 013422743
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/29/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2019
Section Cited
CCR
102417(8)
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Operation of a Family Child Care Home
Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

There is no current roster available.
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By POC Due Date, Licensee will provide a current roster and send to the Oakland Child Care Office.
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This requirement was not met as evidenced by document review and licensee interview. This poses a potential health and safety risk to the children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250.00 per violation and $100 per day until corrected.
Type B
08/29/2019
Section Cited
CCR
102418(g)
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Immunizations
The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

C1 doesn't have immunization records on the blue card.
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By POC Due Date, Licensee will send a copy of the immunization records to the Oakland Child Care Office.
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This requirement was not met as evidenced by document review and licensee interview. This poses a potential health and safety risk to the children in care.
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Failure to correct will result in a $100 per day civil penalty until corrected. Repeat violations are $250.00 per violation and $100 per day until corrected.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Ann RobinsonTELEPHONE: (510) 622-2591
LICENSING EVALUATOR NAME: Caroline ColsonTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3