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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073405134
Report Date: 06/08/2022
Date Signed: 06/08/2022 04:04:35 PM


Document Has Been Signed on 06/08/2022 04:04 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
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612



FACILITY NAME:JACOBS, CARMEN DFACILITY NUMBER:
073405134
ADMINISTRATOR:JACOBS, CARMEN DFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 427-2341
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:14CENSUS: 0DATE:
06/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Carmen JacobsTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Cherie Acosta conducted an unannounced Annual Required inspection. Present during today’s inspection was the licensee, her fingerprint cleared husband and fingerprint cleared granddaughter. There were no children in care today.

The home was toured for Health and Safety Inspection. On limits area consist of the family room, living room, dining room and bathroom located on the first floor. Off limits area consists of the entire second floor, kitchen and garage. Off limits areas will be made inaccessible by use of gates, closed and/or locked doors and visual supervision. The home was observed to be orderly, with heating and ventilation for safety and comfort. There are no pools, spas, hot tubs, or any other similar bodies of water at this home. There are no firearms on the premises as stated by the licensee. Detergents, cleaning compounds, medications and other items which could pose a danger to children are stored and inaccessible to children. Stairs are gated. The fireplace is screened to prevent access by children. LPA verified that the fire extinguisher 3A40BC is fully charged. The home is equipped with both a smoke detector and carbon monoxide detector. There is a working telephone in the home. Outdoor play area is fenced.
File review was conducted. The licensee has current CPR and First Aid which expires 4/20/24. Mandated reporter training was completed 3/7/22

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.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:
DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/08/2022
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: JACOBS, CARMEN D
FACILITY NUMBER: 073405134
VISIT DATE: 06/08/2022
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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.

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/inspection-process

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

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platform.
To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
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: JACOBS, CARMEN D
FACILITY NUMBER: 073405134
VISIT DATE: 06/08/2022
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There are no deficiencies cited during today’s inspection.

A notice of site visit was provided and must be posted for 30 days.
Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Carmen Jacobs.
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Cherie AcostaTELEPHONE: (510) 622-1623
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3