198020110-1-21-2022-33-CC-CGRN-CAVPVR-20220121103934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198020110
Report Date: 01/20/2022
Date Signed: 01/21/2022 10:41:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME:	JACKSON FAMILY CHILD CARE		FACILITY NUMBER:	198020110
ADMINISTRATOR:	NATALIE JACKSON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(626) 676-3770
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	14	CENSUS: 6	DATE:	01/20/2022
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Natalie Jackson		TIME COMPLETED:	02:00 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) Crystal Green conducted an announced required 1- year inspection. LPA met with licensee, Natalie Jackson who guided analyst on a tour of the facility. The licensee's assistant, Alonda Lopez was also present. There were 6 children present, 2 being an infant. Licensee states that there are currently 13 children enrolled. Family members residing in the home are 1 adult (criminal record clearances on file) and 2 children. This is a one story home that consists of 4 bedrooms, 2 restrooms, dining room, living room, den, kitchen, and an attic. Per applicant, Day-care entrance will be from the backyard accessible from Casitas Ave. The children use 2 bedrooms, den, and a restroom located in one of the accessible daycare room. Per licensee, areas off limits to children and parents include: bedroom, child bedroom, bathroom in hallway, living room, dining room, kitchen, and garage. The LPA toured all areas used by children during this visit. Areas accessible to children were inspected to ensure that they are clean and orderly with ventilation and heating for safety and comfort. LPA observed safety gates in place to prevent access to the off-limits area of the home. There were safe toys, play equipment and materials observed for children. There is a working telephone service maintained in the home. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are made inaccessible in some areas of the home. The licensee states that there are no poisons in the home. The licensee does understand that poison must be locked with a key or combination lock. LPA observed and inspected sleeping equipment for infants. LPA observed a crib or play yard for each infant who is unable to climb out of the crib or play yard. All equipment meets the US Consumer Product Safety Commission safety standards. Page 1 of 3.

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Crystal Green	TELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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 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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 198020110
	VISIT DATE: 01/20/2022

NARRATIVE

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LPA observed that cribs and/or play yards are free from loose articles and objects. There are no objects hanging above or attached to the side of the crib. LPA observed that cribs and play yards do not hinder the entrance or exit to and from the space they are sleeping in. Mattresses were observed to be firm and covered with a fitted sheet that is appropriate to the mattress size. Each infant has their individual bedding and is washed weekly as required. Soiled bedding is replaced when wet or soiled and is placed in an area inaccessible to infants. Pacifiers were observed to not be attached to anything and are labeled. Licensee was advised that infants shall not be swaddled while in care and all infants up to 12 months should be placed on their back for sleeping.

LIC 9227 (Individual Sleeping Plan) for infants up to 12 months was explained and issued to the Licensee. Title 22 Regulation Section 102425(j) Infant Safe Sleep was discussed with the Licensee, including but not limited to documentation that shall be maintained.

Per licensee, there are no weapons, firearms or bodies of water on the premises. Children’s records were reviewed to ensure that each child has an Identification and Emergency form. The valve on the required 2A 10BC fire extinguisher indicates fully charged (serviced 11/17/2021). Smoke detector and carbon monoxide detector in the dining room were tested and are in operable condition. The licensee and licensee assistant have current Pediatric First Aid and CPR, which will expire 10/2022.

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

SB792 (Immunization Requirements for Staff and Employees) was discussed with the Licensee. The Licensee and her assistants currently have immunization documentation on file.
Page 2 of 3

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Crystal Green	TELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

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, 1000 CORPORATE CNTR DR. 200-B
MONTEREY PARK, CA 91754

FACILITY NAME: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 198020110
	VISIT DATE: 01/20/2022

NARRATIVE

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The following was discussed:
· Individuals who are 18 years of age or older living in the home must obtain a criminal record clearance. Individuals within one month of their 18th birthday must be fingerprinted immediately. Failure to obtain a criminal record background check clearance prior to initial presence in the home will result in an immediate $100.00 dollar or more per day Civil Penalty.
· The Licensee shall be present in the home and shall ensure that children are supervised at all times.
· Children shall not be left in park vehicles.
· The capacity specified on the license shall be the maximum number of children for whom care can be provided.
· Car seats shall only be used for transportation purposes and shall not be used for sleeping.
· All children in care have the right to receive safe, healthful, and comfortable accommodations, furnishings and equipment.
· When a child shows signs off illness, they will be separated from other children until the nature if the illness is determined.
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LPA reviewed and issued the LIC 311 - Forms/Records to Keep in Your Family Child Care Home.
CHILDREN’S FORMS/RECORDS, FACILITY FORMS/RECORDS and INFORMATION TO BE POSTED, Disaster drills, posting requirements, children records requirements, mandated child abuse and injury/death reporting, and criminal record transfer requirements were discussed.

The Notice of Site Visit (LIC 9213) – must remain posted for 30 days during the hours of operation after each site visit by a licensing representative. Failure to maintain posting as required will result in a civil penalty of $100.00.

At this time, the licensee is in compliance with California Title 22 Regulations. Therefore, there are no citations being issued today.

Exit interview was conducted with Licensee. The Licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these forms.
Page 3 of 3.

SUPERVISOR'S NAME: Christina Gabelman	TELEPHONE: (323) 981-3380
LICENSING EVALUATOR NAME: Crystal Green	TELEPHONE: (323) 980-4930
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2022

LIC809 (FAS) - (06/04)

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