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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406816
Report Date: 08/06/2021
Date Signed: 08/06/2021 04:03:57 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 STE 1102
OAKLAND, CA 94612
FACILITY NAME:JIMENEZ, LINDANFACILITY NUMBER:
073406816
ADMINISTRATOR:JIMENEZ, LINDANFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 828-3784
CITY:SAN RAMONSTATE: CAZIP CODE:
94582
CAPACITY:14CENSUS: 10DATE:
08/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Lindan JimenezTIME COMPLETED:
04:10 PM
NARRATIVE
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On 8/6/2021 at 2:05pm Licensing Program Analyst (LPA) Morgan Pringle met with Licensee Lindan Jimenez for an unannounced annual inspection. Present during the inspection was the Licensee and an uncleared helper. There were six (6) preschool children and four (4) infants present during the inspection. Licensee’s live in the home with her 16 year old daughter and fingerprint cleared husband. The Licensee’s home was toured for a health and safety inspection. The facility operates from 7:00am – 5:30pm.

ON LIMITS AREA: Family Room, Downstairs Bedroom, Downstairs Bathroom, and Backyard


OFF LIMITS AREA: Entire 2nd Floor, Living Room, Kitchen, Dining Room, Laundry Room and Garage
ISOLATION AREA: Downstairs Bedroom

The facility is a two story home rented by the Licensee. The inside of the home is observed to be neat, clean with ample age appropriate materials for the children that are safe and clean. All toxins, cleaning products, medications, and hazardous materials were observed to be in inaccessible areas. Licensee has stated that there no firearms and one (1) dog.

The home has one (1) fully charged 3A40BC fire extinguisher in the Family room. There is one (1) working smoke detector the living room and one in the downstairs bedroom. There is one carbon monoxide detector in the hallway leading to the family room. The home is equipped with central heat and air for proper ventilation.

At 2:45pm LPA obtained the facility roster and the child’s files. All files are complete. The Licensee’s Health and Safety training has been completed and CPR and First Aid training is complete with an expiration date of 4/24/2023. Licensee’s Mandated Reporter training is complete and expires on 10/24/2021. Licensee’s fire and disaster drill log is complete with the last drill logged 5/3/2021. All required forms are posted and visible for public view in the living room. Cont on 809-C
SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
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 STE 1102
OAKLAND, CA 94612

FACILITY NAME: JIMENEZ, LINDAN
FACILITY NUMBER: 073406816
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2021
Section Cited

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102370(d) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing, or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required by the Department or
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This requirement was not met as evidenced by: Licensee has an uncleared adult working as an assistant at the facility. This poses an immediate risk to the health and safety to the children 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: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: JIMENEZ, LINDAN
FACILITY NUMBER: 073406816
VISIT DATE: 08/06/2021
NARRATIVE
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Licensee was reminded that California Law requires licensees to report unusual incidents or injuries to children in care, to child's parents, and to the Department of Social Services using the Unusual Incident/Injury form (LIC 624). Incidents must be reported within 24 hours by phone, fax, or email. LPA informed Licensee that all forms can be downloaded at www.ccld.ca.gov. Licensee was also informed that Mandated Reporter Training ("General" and "Child Care Providers") is required for all staff and is to be renewed every 2 years by visiting www.mandatedreporterca.com.

Licensee is reminded that ALL Licensees, volunteers, frequent visitors, or adults living in the home, that are 18 years of age or older must be fingerprint cleared and associated to this facility prior to being in the presence of children in care or an immediate civil penalty will be assessed from $100 to $3,000 per person, per incident. Licensee was reminded of the responsibility as a mandated reporter.
All fire/disaster drill must be conducted every six months and documented. The Licensee is reminded that any structural changes to the facility or additions to the childcare facility must be reported to Community Care Licensing.

Licensee was encouraged to frequently visit our website at www.ccld.ca.gov for licensing regulations and updates.

This report was read and given to the Licensee for a signature. There is one (1) deficiency being cited today. LIC9224 Acknowledgement of Receipt of Licensing Reports, Appeal Rights and Notice of Site Visit were provided and exit interview conducted. Notice of Site Visit must be posted for 30 days.

SUPERVISOR'S NAME: Jason JangTELEPHONE: (510) 725-7009
LICENSING EVALUATOR NAME: Morgan PringleTELEPHONE: (510) 622-2602
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2021
LIC809 (FAS) - (06/04)
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