197700265-5-19-2022-12-CC-LKIG-CEKSUE-20220519141101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197700265
Report Date: 05/19/2022
Date Signed: 05/19/2022 02:11:11 PM

Document Has Been Signed on 05/19/2022 02:11 PM - 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME:	JACKSON FAMILY CHILD CARE		FACILITY NUMBER:	197700265
ADMINISTRATOR:	JACKSON, LARHONDA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 291-7050
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	14	CENSUS: 3	DATE:	05/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	LaRhonda Jackson		TIME COMPLETED:	02:15 PM

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	Licensing Program Analyst (LPA) King-Lewis conducted a required 1 year Inspection with licensee. LPA observed 3 children in care . LPA was guided on a tour of the home day-care area. The day care take place in the following area of the home: bonus room, family room, dining area hallway bathroom, and rear yard. No body of water on the premises. Licensee states the day care hours of operation is less than 24 hours a day 7 days a week. Currently living in the home are licensee, licensee’s 2 minor children, 2 guardianship and 2 resource placement. During the inspection LPA observed the facility Physical Plant, Care and Supervision, Facility Records Review, and Facility Administration. LPA discussed safe sleep regulation and informed licensee to refer to regulation 102425(J) for documentation requirement. LPA reviewed requirement with licensee during this inspection. Licensee shall supervise infants while they are sleeping by physically checking every 15 minutes and documenting the child status in writing. Licensee was informed all infants shall have an individual infant Sleeping Plan (LIC 9227). Licensee aware no infant shall be swaddle, car seat shall not be used for sleeping, LPA provided Child Care Licensing Safe Sleep web page as an additional resource: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

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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Document Has Been Signed on 05/19/2022 02:11 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 197700265
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102417(g)(9)(A)

Operation of A Family Child Care Home

(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/24/2022
	Plan of Correction
1 2 3 4	Licensee shall forward a copy of the fire drill to assigned LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 197700265
	VISIT DATE: 05/19/2022

NARRATIVE

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LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. To provide Incidental Medical Services, such as administering blood glucose monitoring, inhaled medications, Epi-pen and Epi-pen Jr., insulin shots, gastrostomy tube feeding and care, or carrying out other medical orders, it is best practice to complete a “Plan for Providing Incidental Medical Services”. This plan will help you ensure that you can provide this service in the safest manner possible. A Plan for Providing IMS must be submitted to the Department.

Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident on the form LIC624B per the regulation. The report unusual incident/injuries report should be emailed to UnusualIncidentReport@dss.ca.gov

During this inspection facility was not observed to be in compliance with Title 22. See LIC 809D

For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.

Exit interview conducted and report was reviewed with the licensee a copy of this report and a notice of site visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Mariela Ramon	TELEPHONE: (661) 202-3798
LICENSING EVALUATOR NAME: Lady King	TELEPHONE: (661) 568-8933
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022

LIC809 (FAS) - (06/04)

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