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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 053622109
Report Date: 08/07/2023
Date Signed: 08/07/2023 01:16:45 PM


Document Has Been Signed on 08/07/2023 01:16 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: 9DATE:
08/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee Jennifer HendersonTIME COMPLETED:
01:25 PM
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On August 07, 2023, Licensing Program Analyst (LPA) Tobias Lake met with Licensee, Jennifer Henderson, for the purpose of an unannounced annual inspection as well as to clear a plan of correction for a previous citation. There were nine children present at the time of inspection. Licensee's staff Jordan and Reese were also present during the inspection. Licensee's operating hours are Monday through Friday from 7:00 AM. to 5:30 PM. LPA verified the annual fees are current.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.
A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include garage, master bed/bath, and two children’s rooms. Off limit areas are being made inaccessible by closed locked doors and child-proof doorknobs. LPA observed the required postings and a working phone. 3A40BC fire extinguisher meets regulations. LPA observed smoke and carbon monoxide detectors, and verified they were both functional. LPA toured the kitchen area and verified knives and cleaners were inaccessible to children in care.
Licensee stated there are weapons and pets in the home. Licensee stated they keep their dogs separate while children are in care. LPA verified firearms were locked appropriately in a gun safe in the garage. There was no ammo present and Licensee states ammo is kept at another home entirely. Outdoor play space is fenced. LPA observed living room area with age-appropriate toys for children. LPA observed a restroom and verified that hazardous and toxic items were inaccessible to children in care. The backyard has an above-ground pool area that is fenced per Title 22 regulations and LPA observed the gate to self-close and self-latch. There are no windows or doors that provide direct access into the pool area.
Report continues 809-C.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Tobias LakeTELEPHONE: 916-224-9388
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2023
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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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
VISIT DATE: 08/07/2023
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LPA discussed the safe sleep regulations with licensee 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 licensee 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. In addition, LPA observed 15min infant napping logs for infants 24 months and under. LPA observed LIC 9227 Individual Sleeping Plans, for infants under 12 months, for licensee during today's inspection.

Children's files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and documentation that a fire drill is conducted at least once every six months. Licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in-person EMSA pediatric CPR and First Aid certification was verified and expires 01/2024 and Child Care Provider Mandated Reporter certification was expired. LPA discussed requirement to renew mandated reporter training every two years.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-carecenters/.
Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.
To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process
Report continues 809-C.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Tobias LakeTELEPHONE: 916-224-9388
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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
VISIT DATE: 08/07/2023
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Exit interview conducted and report was reviewed with the licensee, Jennifer Henderson. Licensee was encouraged to visit the Department website at www.ccld.ca.gov/ for childcare updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. Licensee's signature on this form acknowledges receipt of this form. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, no deficiencies were cited during today’s inspection.
SUPERVISOR'S NAME: Jeanne SmithTELEPHONE: (916) 208-4405
LICENSING EVALUATOR NAME: Tobias LakeTELEPHONE: 916-224-9388
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2023
LIC809 (FAS) - (06/04)
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