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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053622109
Report Date: 07/05/2023
Date Signed: 07/05/2023 01:44:00 PM


Document Has Been Signed on 07/05/2023 01:44 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
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:HENDERSON, JENNIFERFACILITY NUMBER:
053622109
ADMINISTRATOR:JENNIFER HENDERSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 649-6497
CITY:VALLEY SPRINGSSTATE: CAZIP CODE:
95252
CAPACITY:14CENSUS: 12DATE:
07/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Licensee, Jennifer HendersonTIME COMPLETED:
02:00 PM
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On 07/05/2023, Licensing Program Analyst (LPA) Tobias Lake arrived at the facility for the purpose of a complaint investigation. During the tour of the facility, LPA observed an above-ground pool structure filled with water in the back yard. The pool was uncovered and only surrounded partially by a plastic baby gate. Licensee stated that the pool was only recently purchased for the recent holiday. Licensee stated they will purchase an appropriate fence in order to bring the pool into compliance.

A Title 22 deficiency is cited on LIC 809-D. Licensee acknowledges, that for TYPE A DEFICIENCIES ONLY upon receipt, Licensee shall post LIC 809-D with Type A deficiency for 30 days and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months. LIC9224 must be signed by parents/guardians and kept with the children's forms as a receipt whenever any Type A documents are provided by the Licensee. LIC9224 and Appeal Rights were provided.

An exit interview was conducted. The Notice of Site Visit (LIC 9213) was posted where the parent/guardian of children enter and exit the facility. The Notice of Site Visit (LIC 9213) must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Tobias LakeTELEPHONE: 916-224-9388
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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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Document Has Been Signed on 07/05/2023 01:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: HENDERSON, JENNIFER
FACILITY NUMBER: 053622109

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2023
Section Cited
CCR
102417(g)(5)(B)

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102417(g)(5)(B) Operation of a Family Child Care Home (g)(5)...licensees shall ensure the inaccessibility of pools... (B)...above-ground pool structure... shall be made inaccessible... erecting a barricade to prevent access...This requirement was not met as evidenced by:
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Licensee will purchase and install a fence that meets regulations to surround the above-ground pool. If Licensee is unable to obtain an adequate fence, Licensee will drain the pool and take it down.
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Based on observation, it was determined that a pool is accessible to children in care which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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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: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Tobias LakeTELEPHONE: 916-224-9388
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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