073404261-6-15-2023-02-CC-NBLT-CSTNLG-20230615103332

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 073404261
Report Date: 06/15/2023
Date Signed: 06/15/2023 10:33:42 AM

Document Has Been Signed on 06/15/2023 10:33 AM - It Cannot Be Edited

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:	JACKSON, BILLIE		FACILITY NUMBER:	073404261
ADMINISTRATOR:	JACKSON, BILLIE		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(510) 758-7660
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	14	CENSUS: 7	DATE:	06/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	JACKSON, BILLIE		TIME COMPLETED:	11:00 AM

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On June 15, 2023 at 09:00 AM, Licensing Program Analyst (LPA) Nyeesha Blount met with Licensee Jackson, Billie and husband who is background cleared for an unannounced random annual inspection. There are (2) infants, (2) toddler and (3) school age children present during the time of the inspection. The facility’s operating hours are Monday -Friday 6:30AM to 6:00PM. LPA toured all on limits areas of the facility for health and safety inspection. All required postings are posted in the activity room on the wall..

The home is a Two story home ,Which consists of a living room, dining room, kitchen, (3) bedrooms, (2) bathrooms, upper and lower deck, fenced backyard, and garage. The home is neat and clean and has central heating and ventilation for safety and comfort. There are sufficient age appropriate furnishings, toys, books and learning materials available. Licensee states that there are no weapons in the home. All hazardous materials and toxins are stored away inaccessible to children in care at the time of the inspection. The home is equipped with a 3A40BC fire extinguisher, working smoke detector, and working carbon monoxide detector. Pediatric CPR and First Aid are current and will expire on October 10, 2024.

ON LIMIT AREAS: Living room, dining room, activity room, changing room, (1) bathroom, and backyard.

OFF LIMIT AREAS: will be the kitchen, entire upstairs secured with latches and gates made inaccessible to the children in care.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha Blount	TELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JACKSON, BILLIE	FACILITY NUMBER: 073404261
	VISIT DATE: 06/15/2023

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OUTDOOR SPACE: The backyard. The entire area was inspected to ensure the health and safety of the area. All play structures are properly secured. There is a pool with a locked black iron rod fence made inaccessible to the children in care on the premises during today's inspection.

ISOLATION AREA: will be in the changing room.

LPA reviewed the facility staff and children's records including parents' rights forms, emergency ID forms and consent for emergency medical treatment forms. Licensee CPR/First Aid, Mandated Reporter Certificate for licensee is currently expired.

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.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha Blount	TELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JACKSON, BILLIE	FACILITY NUMBER: 073404261
	VISIT DATE: 06/15/2023

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Per 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 http://www.ada.gov/childqanda.htm

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Licensee was reminded about importance to stay in compliance with mandated reporter training and maintenance of sleep logs for all infants in care. In the areas that were evaluated, Technical violation were observed.

A NOTICE OF SITE VISIT WAS GIVEN AND MUST REMAIN POSTED FOR 30 DAYS. Exit interview conducted and report was reviewed with the licensee Jackson, Billie.

SUPERVISOR'S NAME: Mayla Mendoza	TELEPHONE: (510) 292-9724
LICENSING EVALUATOR NAME: Nyeesha Blount	TELEPHONE: (510) 566-2319
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC809 (FAS) - (06/04)

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