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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197401041
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:44:11 AM


Document Has Been Signed on 11/01/2022 11:44 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245



FACILITY NAME:JACKSON FAMILY DAY CAREFACILITY NUMBER:
197401041
ADMINISTRATOR:JUDY JACKSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(310) 415-1944
CITY:WILMINGTONSTATE: CAZIP CODE:
90744
CAPACITY:12CENSUS: 2DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:JUDY JACKSON, LICENSEETIME COMPLETED:
12:00 PM
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On 10/14/2022 @ 10:30 AM, Licensing Program Analyst (LPA) Miriam Cohen, conducted an unannounced Annual Required Inspection and was met by Licensee, Judy Jackson. Hours of operation are from Monday thru Friday from 6:00 AM – 6:00 PM. LPA toured the home inside and outside and a census was taken. Current facility sketch reviewed, and Licensee confirmed that all bedrooms are off limits and made inaccessible by use of locks. This is one-story home was inspected as follows: living room, dining room, kitchen, two bedrooms and two bathrooms, front yard and backyard, and a detached garage. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPA confirmed the phone number is (310) 415-1944. LPA discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are 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. Infants are not swaddled while in care. Provider physically checks 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. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping. 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. The outdoor play area in the backyard is fenced and there are no hazards to children present. Capacity as specified on the license is being maintained. Licensee’s pediatric CPR/First Aid expires on 12/2022. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Miriam CohenTELEPHONE: (424) 301-3058
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACKSON FAMILY DAY CARE
FACILITY NUMBER: 197401041
VISIT DATE: 11/01/2022
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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 not currently 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.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, no deficiencies are cited.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficienc(y)ies is/are being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.
Upon receipt of a Type A violation, licensee shall post and provide copies of this licensing report to parents/guardians of children in care at the facility and to parents/guardians of children newly enrolled at the facility during the next 12 months.

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.
A copy of this report was explained and issued to licensee.
SUPERVISOR'S NAME: Maureen NealTELEPHONE: (424) 301-3042
LICENSING EVALUATOR NAME: Miriam CohenTELEPHONE: (424) 301-3058
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
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