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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073407802
Report Date: 08/18/2023
Date Signed: 08/18/2023 11:05:05 AM


Document Has Been Signed on 08/18/2023 11:05 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:FERNANDES, JENNIFERFACILITY NUMBER:
073407802
ADMINISTRATOR:FERNANDES, JENNIFERFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 812-3744
CITY:PACHECOSTATE: CAZIP CODE:
94553
CAPACITY:14CENSUS: 3DATE:
08/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:JENNIFER FERNANDESTIME COMPLETED:
11:15 AM
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Licensing Program Analyst Tasha Alexander met with licensee Jennifer Fernandes for an unannounced 1 YEAR/REQUIRED inspection. Present for today's inspection is licensee, and 3 preschool age children in care, 2 of which are the licensee's own children. LPA toured the facility and backyard for a health and safety inspection. The children's files were also reviewed. There is a fully charged 2A10BC fire extinguisher and a working smoke alarm/carbon monoxide detector combo in the home. Both were tested today and found to be in working condition. There is a working telephone in the home, no change in the phone number. There is a fire arm in a gun safe located in the off limits master bedroom. The ammunition is stored separately in the off limits garage in a locked safe. There is a hot tub located in the backyard that has a hard cover that can withstand the weight of an adult and has locks on all 4 sides. All poisons, cleaning solutions and medications are inaccessible to children in care. Licensee has current CPR & 1st AID cards which expire 9/2023 respectively. THE OFF-LIMIT AREAS ARE:The entire upstairs which includes the children's 2 bedrooms, the downstairs master bedroom and laundry room. These areas will be inaccessible to children in care by closed and/or locked doors, visual supervision and a safety gate at the bottom of the stairs. THE ON LIMIT AREAS ARE: The 2 front rooms, bath room, kitchen and backyard. Licensee was reminded that baby walkers, excersaucers and baby bouncers are not allowed. Licensee was also informed of the licensing web address (www.ccld.ca.gov) for downloading child care forms and (www.myccl.com) to register to receive child care updates.

Licensee [or facility representative] 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: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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: FERNANDES, JENNIFER
FACILITY NUMBER: 073407802
VISIT DATE: 08/18/2023
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A review of staff records on 8/15/23 indicates that all facility staff or other individual who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Effective September 1, 2016, a person may not work or volunteer at a child care center or family child care home unless he or she has been vaccinated against pertussis, measles and influenza or has an exemption. Licensee has immunization records in file. Licensee declines the flu vaccine

Today the mandatory mandated reporter training course was also discussed. Licensee's certificate is up to date. expiring 3/2024

Infant Safe Sleep practices were discussed. Licensee has a pack n play for infant napping. A copy of the Infant Safe regulations and the infant sleep log was given today.

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

CONTINUED ON 809-C

SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
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: FERNANDES, JENNIFER
FACILITY NUMBER: 073407802
VISIT DATE: 08/18/2023
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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.

AS A RESULT OF TODAY'S VISIT THERE ARE NO DEFICIENCIES CITED TODAY


An exit interview was conducted. A notice of site visit was posted.
SUPERVISOR'S NAME: Loretta DysonTELEPHONE: (510) 695-0243
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 292-9724
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3