153805531-4-28-2023-57-CC-JPEE-CRBP4H-20230428105911

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 153805531
Report Date: 04/28/2023
Date Signed: 04/28/2023 10:59:23 AM

Document Has Been Signed on 04/28/2023 10:59 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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME:	CASA HOGAR JACOBO		FACILITY NUMBER:	153805531
ADMINISTRATOR:	JACOBO, BERTHA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(661) 454-6591
CITY:	DELANO	STATE: CA	ZIP CODE:	93215
CAPACITY:	14	CENSUS: 4	DATE:	04/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Berta Jacobo		TIME COMPLETED:	11:15 AM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On 04/28/2023, Licensing Program Analyst (LPA), Jose Penate, conducted an unannounced Annual Required Inspection and was met by Licensee, Berta Jacobo and assistant (Spanish speaking). Days/Hours of Operation: Monday through Friday, 5:00 AM to 5:00 PM.

LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Licensee confirmed rooms accessible for children to use is the living room, dining room, kitchen, hallway bathroom, large day care room and attached half bath. and backyard. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. No poisons were observed during the inspection.

There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. The home has working telephone service and LPA confirmed the phone number is (661) 454-6591.

LPA and licensee discussed Safe Sleep Regulations. Licensee is aware that cribs and play yards are to be kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard.

Provider is aware to physically check on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Individual Infant Sleeping Plan is to be completed for each infant up to 12 months of age upon enrollment. LPA discussed with licensee, Infants up to 12 months of age shall be placed on their backs for sleeping.

(Continued on 809-C)

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

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
FRESNO SOUTH CC, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: CASA HOGAR JACOBO	FACILITY NUMBER: 153805531
	VISIT DATE: 04/28/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children. Capacity as specified on the license is being maintained.

LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensees Mandated Reporter Training was completed on 10/22/2021. Licensee’s pediatric CPR/First Aid expires on 03/24/2025. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.

Incidental Medical Services (IMS) are currently not being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are being cited.

Exit interview conducted and report was reviewed with Licensee, Berta Jacobo.

This report shall be made available to the public upon request.

LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.

SUPERVISOR'S NAME: Duane Matsubara	TELEPHONE: (559) 650-7855
LICENSING EVALUATOR NAME: Jose Penate	TELEPHONE: (559) 341-5860
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2