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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075700205
Report Date: 10/02/2019
Date Signed: 10/02/2019 02:03:21 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, KARINAFACILITY NUMBER:
075700205
ADMINISTRATOR:JIMENEZ, KARINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 248-3508
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:14CENSUS: 1DATE:
10/02/2019
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:KARINA JIMENEZTIME COMPLETED:
01:11 PM
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Licensing Program Analyst Lakeisha Chew met with Karina Jimenez for the purpose of an Announced Relocation and Capacity Increase Prelicensing Inspection. Present for the visit was the Applicant, and one (1) infant in care. Applicant Karina Jimenez, guided LPA on a tour of the home. All areas identified on the facility sketch were inspected. This residence is a single-story home which consist of four (4) bedrooms, two (2) bathrooms, living room/ formal dining room (child care area), kitchen, family room, office (converted bedroom), attached 2 car garage and fenced backyard. Applicant states she resides in the home solely. This home plans to operate Monday through Friday from 7:30am until 6:00pm. All REQUIRED forms will be posted and visible for public review in the entryway of home. LPA observed the home has child safety outlet plugs cover, and barrier gates throughout home. There are age appropriate toys on the premises. An evaluation of the overall condition of this residence including telephone service, heating, and ventilation is in compliance standards for safety and comfort. This home met all Title 22 Regulations at the time of the inspection. San Ramon Valley Fire Protection Department conducted a fire inspection on 08/05/2019 and this home was granted a Fire Clearance with special conditions, garage off-limits to children in care. There are no pools, hot tubs or any other bodies of water accessible to children, during today’s visit. Applicant rent the property. Proof of control was provided during the inspection and copy obtained for file. The required fire extinguisher 2A-10B:C, carbon monoxide detector and smoke detector and fully stocked first-aid kit were inspected and met regulations. Per applicant there are no weapons, firearms or ammunition in the home, currently. Applicant Preventative Health and Safety training was completed on March 31, 2018. Pediatric CPR and First Aid certificates are current and expire on February 02, 2021. Mandated Reporter Training is current and expire on August 01, 2021. The applicant has submitted proof of immunization for influenza, pertussis and measles and met new immunization law which pertains to day care providers. Areas off-limits include: Garage, Kitchen area, dining room, Office, two (2) bedrooms and one (1) Master bathroom, Areas Isolation include: First bedroom on right side (children nap room).The Applicant state the securely screened fireplace in the dining room is a non-operating. Continuation 809-C
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Lakeisha ChewTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2019
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 STE 1102
OAKLAND, CA 94612
FACILITY NAME: JIMENEZ, KARINA
FACILITY NUMBER: 075700205
VISIT DATE: 10/02/2019
NARRATIVE
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All hazardous materials and toxins are kept out of the reach of children and it was observed that there were no toxins or hazardous items accessible today. The Applicant has three (3) dogs. Back Yard Area: There are age appropriate toys and materials that are safe and in good condition The following were discussed: Applicant is reminded that ALL assistants, 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 $3000 per person, per incident. Applicant was reminded of the responsibility as a mandated reporter. All forms can be downloaded at www.ccld.ca.gov.http://www.myccl.gov/. No smoking. No Infant Bouncers, Saucer Chairs, Johnny Jumpers, Baby Walkers, Baby Bouncers, or any such similar article that falls into that category. Posting requirements: Earthquake Preparedness Checklist, Fire/Earthquake Evacuation drill, Parent’s Rights, Child Passenger Safety Law, Nutritious Beverage Law, Safe Sleep Regulation Concept, Children Records Requirements, Mandated Child Abuse and Injury/Death Reporting, Criminal Records, Child Abuse Clearance and Criminal Records Transfer Requirements. Children Records: LIC: 700 Identification and Emergency Information, 702 Child’s Pre-admission Health History LIC 995E Caregiver Background Check Process, 995A Notification of Parent’s Rights, 627 Consent for Emergency Medical Treatment, 613A Personal Rights, LIC282 Affidavit Regarding Liability Insurance, LIC9150 Parent Notification, Additional Children in Care. Facility Records: LIC9149 Property Owner/Landlord Consent, PUB 394 Notification of Parents Rights, PUB 269 California Child Passenger Safety Law, LIC 9040 Facility Roster, LIC624A Death Report, LIC6101A Emergency Disaster Plan, LIC9148 Earthquake Preparedness Checklist, LIC 624 Unusual Incident/Injury Report. Staff Records: LIC 508 Criminal Record Statement, LIC 501 Personnel Record, LIC 503 Health Screening/TB, LIC9052 Employee Rights, LIC9108 Statement Acknowledging Requirement to Report Child Abuse, LIC 9163 Request for LIVESCAN, LIC9188 Criminal Record Exemption Transfer Request, LIC 9182 Criminal Background Clearance Transfer Request, LIC9052 Employee Rights. 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. Effective August 1, 2003 California Law requires Family Child Care Home 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 624B). Incidents must be reported within 24 hours by phone, fax, and mail. Applicant has been advised of the following Fire and earthquake drills to be conducted every six months. Outdoor supervision required at all times. A copy of this report and all other Licensing reports must be made available to the public for 3 years. Exit interview conducted with Applicant, Karina Jimenez
SUPERVISOR'S NAME: Sherelle JohnsonTELEPHONE: (510) 622-2592
LICENSING EVALUATOR NAME: Lakeisha ChewTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2019
LIC809 (FAS) - (06/04)
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