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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197493200
Report Date: 07/17/2019
Date Signed: 07/17/2019 04:25:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME:JACQUEZ FAMILY CHILD CAREFACILITY NUMBER:
197493200
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 3DATE:
07/17/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Rebekkah JaquezTIME COMPLETED:
04:40 PM
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Licensing Program Analyst's (LPA's) Maddox and Smith conducted an annual random inspection with a Capacity Increase at the above facility. LPA Maddox and Smith met with licensee, Rebekkah Jaquez, who guided analyst on a tour of the facility. Present during this inspection was Licensee's adult sister Laura who is fingerprint cleared. This is a single family home 3 bedroom 2 bath home. The home was inspected inside and out for safety, comfort, cleanliness, telephone service, heating and ventilation, inaccessibility to poisons, detergents, cleaning compounds, medicines, sharp and hazardous items that can pose a danger to children. Fireplace is screened and inaccessible to children. The kitchen and bathroom was inspected for inaccessibility of chemicals/toxins and other potential hazards to children in care. There is a Fire Pull system in the kitchen. Cabinets and drawers were inspected for inaccessibility of toxins/chemicals, knives and other sharp objects which may be harmful to children in care.

Per Licensing Information System (LIS) all adults residing and working in the home have obtained background clearances. Per LIS, facility annual fees are current. Per facility sketch no children were in areas identified as off limits. The licensee is operating within proper capacity and ratios. The home is sanitary, orderly, comfortable, and well ventilated for safety and comfort. LPA observed licensee to be present at the home and providing adequate care and supervision for 3 preschool aged children who were napping on mats in the Day Care Living Room. Per licensee, there are no weapons or firearms of any kind in the facility at this time. The LPA did not observe any weapons or firearms. There is no pool, spa or other bodies of water on the premises. There are age appropriate toys and napping equipment on the premises available to the children. The backyard is well fenced all around and inspected and observed to be free of hazards, loose, or sharp objects. Outdoor play equipment was inspected for safety, cushioning material, good repair and age appropriateness. LPA's observed fire and disaster drills, which are conducted every month. Child files, roster, and First Aid kit was observed and complete. Smoke/Carbon detectors are in operable condition. Fire Extinguisher is fully charged. Licensee has current CPR/First Aid valid (11/18/18 - 11/18/20 ), Immunization's are current. Licensee has the required Facility License (LIC 203), Emergency Disaster Plan (LIC610a), Notification of Parents' Rights Poster (PUB 394), Child Care Facility Roster (LIC9040), and Disaster Drill log posted and visible to parents.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Suzanne SmithTELEPHONE: (661) 305-3012
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: JACQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197493200
VISIT DATE: 07/17/2019
NARRATIVE
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The following were discussed: No smoking, No infant walkers, Johnny jumpers, exersaucers and any other item that falls into that category. The LPA also discussed earthquake safety and necessity of drills, required forms for children’s files, facility files and posting requirements and penalty. Fingerprint clearance, transfer process and penalty. The regulation 102416.3 Alterations to Existing Buildings or Grounds. The Parent Notification AB633 and the licensee discipline practiced by the licensee.

The following Incidental Medical Services (IMS) were discussed.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

No deficiencies were observed at the time of the visit. An exit interview was conducted and a copy of this report was submitted to licensee.

A copy of this report must be made available to the public for 3 years.

Licensee was informed that she is a mandated child abuse reporter with the responsibility of reporting any suspected child abuse to the Child Abuse Hotline at (800) 540-4000.

For additional information and forms visit our website at: www.cdss.ca.gov



For updates on Community Care Licensing please visit the following website at: Childcareadvocatesprogram@dss.ca.gov
https://ccld.childcarevideos.org/

An exit Interview was conducted, a copy of this report was read and provided and a Notice of Site visit was given to licensee.

SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Suzanne SmithTELEPHONE: (661) 305-3012
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: JACQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197493200
VISIT DATE: 07/17/2019
NARRATIVE
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The following was discussed with the Licensee:
Capacity requirements, Notification of Parent's Rights, Roster requirements (keep updated names), Documentation requirements for disaster drills (fire and earthquake). Mandatory Forms for the children’s files and provider’s files, Safe Sleep and information on shaking baby syndrome. The role and responsibilities of being a mandated reporter were reviewed. Licensee reminded that 100% supervision is required at all times to children in care. Licensee was advised on how to access forms and Regulations for Family Child Care online at www.ccld.ca.gov. Licensee was made aware that it is her responsibility to know the regulations as well as anyone who assists in providing care. Licensee advised that inaccessibility of hazards must be constantly reassessed depending on the children in care. Licensing must have the facility’s phone number at all times; if the phone number is changed, licensing must be notified. Regulation prohibits the smoking of tobacco in a private residence that is licensed as a family child care home and in those areas of the family day care home where children are present (24/7 ban).

Licensee was advised that the Notice of Site Visit must be posted at the entrance of the facility for a period of 30 days. If a serious violation is cited, a copy of the licensing report (LIC809 or LIC9099) must also be posted for 30 days. If these requirements are not met, civil penalties in the amount of $100 per violation will be assessed. Copies of the reports must also be provided to each parent when a serious deficiency, Type A, is cited (LIC9224).

Licensee informed to review Quarterly updates/regulations for 2015-2019 on the department website: Summer 2015 - Incidental Medical Services information.
SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Suzanne SmithTELEPHONE: (661) 305-3012
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1605 EAST PALMDALE BLV, STE A
PALMDALE, CA 93550
FACILITY NAME: JACQUEZ FAMILY CHILD CARE
FACILITY NUMBER: 197493200
VISIT DATE: 07/17/2019
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--Licensee is advised visit www.shotsforschool.org for Immunization information.
--Licensee was informed of responsibility to report suspected Child Abuse, 1-800-827-8724/760-243-6640
--Family Child Care Providers (Disaster Planning information):https://cccld.childcarevideos.org/family-child-care-providers/disaster-planning-and-fire-safety/
--Child Care Advocates information: www.childcareadvocatesprogram@cdss.ca.gov
--Child Care Videos: https://ccld.childcarevideos.org
--Licensee advised to visit the CCL website (www.ccld.ca.gov) to obtain updates of courses and updates/changes to the regulations.

Licensee advised of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within the time frame specified by the regulation (call within 24 hours and submit written report within 7 days) and on the form LIC624B. Pamphlet Information regarding Safe Sleep Awareness Campaign (PIN 19-02-CCP) and Safe Sleep Regulation Concepts, PIN 19-04-CCP 2018 Chartered Legislation Affecting Child Care Facilities: Summary and Implementation and Notification of Parent's Rights. The information regarding new legislation with regards to exemptions and Parent’s Rights was also discussed. Director reminded to review PIN 19-08 CCP, California Department of Public Health New Pre-Kindergarten (Child Care) and School Immunization Requirements. The "Notification of Parent's Rights" poster must be posted in an area of the home accessible to parents. The information regarding new legislation with regards to exemptions and Parent’s Rights was also discussed.

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 aPln 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

The On Duty Worker is available for questions at 661-789-6944 Monday through Friday 8am-5pm. LPA provided consultation (Safe Sleep) during the inspection.

No deficiencies. An exit interview was conducted and a copy of this report was read and provided to the Licensee on this date.

SUPERVISOR'S NAME: Carissa BellTELEPHONE: (661) 789-6953
LICENSING EVALUATOR NAME: Suzanne SmithTELEPHONE: (661) 305-3012
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2019
LIC809 (FAS) - (06/04)
Page: 4 of 4