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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073408970
Report Date: 10/10/2019
Date Signed: 10/10/2019 03:59:17 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, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:LEE, JASMINEFACILITY NUMBER:
073408970
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 0DATE:
10/10/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:JASMINE LEETIME COMPLETED:
04:00 PM
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LPA Tasha Alexander met today with for an ANNOUNCED PRELICENSING inspection. Applicant was the only one present for the inspection. The home is a two story consisting of 4, 3 bathrooms, living room, family room, kitchen, dinning room, laundry room, bonus room and garage. The living room and downstairs bathroom will be used as the primary areas for day-care. The off limit areas will be the entire upstairs, laundry room, bonus room which is located adjacent to the day care room through the glass doors, the garage and the backyard. 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. Applicant rents the home; proof was shown. There is a 2A10BC fire extinguisher, and working smoke detectors/carbon monoxide combo; recommended periodic servicing. There are 3 firearms in the home. The guns are stored in the off limits master bedroom closet, in a locked safe and the ammunition is stored separately in locked box. There is a swimming pool located in the backyard that is surrounded by a self latching gate that meets the California State Marshall Standards. There is also an empty fountain located in the backyard that is packed with dirty. All sharp knives, cleaning solutions and medications are inaccessible to children. First aid kit is available and complete. The isolation area for sick children will be the family room. outdoor play will be at the nearby park. There are toys and play space available. Applicant was instructed to conduct and document periodic fire and disaster drills. Applicant was informed that baby walkers, exersaucers and baby bouncers are not allowed. Applicant has completed CPR and first aid training which expires in 5/6/20 respectively. Applicant has completed her 16 hours of health and safety training.
Mandated reporter and appeal rights were discussed. Licensing forms were reviewed and copies given to applicant. Applicant was instructed on the law establishing a $100 fine per day for adults who are living in the home or who are providing care who do not have fingerprint clearances. Applicant was also instructed on the law requiring notification to parents regarding exclusions.
All forms can be downloaded at www.ccld.ca.gov. www.myccl.gov for day-care updates.
SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019
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 2
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: LEE, JASMINE
FACILITY NUMBER: 073408970
VISIT DATE: 10/10/2019
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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

There are no deficiencies cited today. This home will be licensed as of today 10/10/19

SUPERVISOR'S NAME: Wynn NoronaTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2019
LIC809 (FAS) - (06/04)
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