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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198400240
Report Date: 06/29/2020
Date Signed: 06/29/2020 04:09:52 PM

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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME:JACKSON FAMILY CHILD CAREFACILITY NUMBER:
198400240
ADMINISTRATOR:SHAWNTAYZIA A. JACKSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(562) 556-3416
CITY:CARSONSTATE: CAZIP CODE:
90746
CAPACITY:14CENSUS: 0DATE:
06/29/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Shawntayzia Jackson, LicenseeTIME COMPLETED:
04:15 PM
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*****PAGE 1*****
This was a pre-licensing inspection conducted by Susann Sanchez, Licensing Program Analyst (LPA), due to COVID19 and precautionary measures this pre licensing- change of location inspection was conducted with Shawntayzia Jackson, applicant/ licensee via a tele-inspection by use of Facetime.

During this tele-inspection the Licensee took this LPA on a tour of the home. Tour began at 2:06pm. During this tour the following was noted: Per Licensee, family members residing in the home are 2 adults and 0 children. Per Licensee, operation hours will be Monday to Sunday, 4:00am to 12:00am Licensee states that she will care for children 0-13 years of age.

All areas identified on the facility sketch were inspected, including but not limited to, off limit areas. This is a one story home that consists of 3 bedrooms, 2 restrooms, dining area, living room, kitchen, sun- room/ daycare room, garage, backyard, and front yard.

Per applicant, the children will use the restroom in the hallway, dining area, living room (only as isolation area), sun-room/ day-care room, and backyard. Areas that will be used by children were observed for safety, comfort, cleanliness, telephone service (cell phone), ventilation and heating. Detergents, cleaning compounds, medicines, sharp objects and hazardous items that can pose a danger to children are inaccessible and are kept in a locked cabinet under the kitchen sink. During inspection LPA observed hair products under the restroom sink. Per applicant will remove product or install latches to keep out of reach to children.

Based on the Facility Sketch submitted, areas off limits to children and parents are: All bedrooms, kitchen, garage and front yard. LPA observed all off- limit area are locked and there is a gate blocking the kitchen. The applicant understands that licensing staff may have access to off-limit areas during inspection visit if necessary.
SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2020
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 5
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 198400240
VISIT DATE: 06/29/2020
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*****Page 2******
OUTDOOR PLAY AREA: The children will use the back yard for outdoor play, which was observed to be fenced. Licensee stated that children will be physically and visually supervised at all times. LPA observed toys and bikes in the backyard.

PETS: Per licensee there are no pets in the home.
BODIES of WATER: Per applicant, there are no bodies of water on the premises.
FIREARMS/WEAPONS: Per applicant, there are no fire arms or weapons on the premises.

The value on the 2A10BC fire extinguisher indicates fully charged, however due to COVID19 Licensee states that it has been challenging to get fire extinguisher serviced. The tag on the fire extinguisher shows it was last serviced on 04/16/2019. Smoke and carbon monoxide detectors were tested and are operable.

There are toys available for children. The applicant states that they will provide food for children in care which include breakfast, lunch and two snacks.

Applicant has completed the required Health and Safety Training, Nutrition Training and Pediatric First Aid and CPR which expires 03/20/2021. There are first aid supplies available.

The following was discussed with the applicant:
· 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. Civil Penalties will be assessed if not in compliance.
· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current Pediatric First Aid and CPR training, Immunizations (TDAP, MMR, Influenza), mandated reporter training and a valid criminal record clearance associated to the facility license.
· Annual fees must be paid promptly and by the due date or a late fee shall be assessed and/or the License may be terminated.
· The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked and batteries replaced as needed.
· Reporting Requirements: Changes should be reported to the Department as soon as they occur such as construction, remodeling, telephone number changes and/or if you move from your home.
SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2020
LIC809 (FAS) - (06/04)
Page: 2 of 5
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 198400240
VISIT DATE: 06/29/2020
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PAGE 3
Reporting Requirements: Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.
· Fire and safety drills must be performed every six months and documented for review by the Department.
· Smoking is prohibited in a family child care home.
· Children and Staff records must be maintained and updated as needed and must be available for review by the Department.
· No infant walkers, No Johnny jumpers, No saucer chairs, No trampolines and any other item that falls into that category are not permitted in the facility.
· Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection the home, which includes, but is not limited to the right to enter the home when children are being cared for, interview children and adults and review documentation.
· The facility license number must be on all advertisements, publications or announcements with the intent to attract clients.
· Isolation for Ill children: When a child is ill he/she shall be separated from other children (reference 102417(e) Operation of a Family Child Care Home). Isolated area will be in the living room.
· Liability Insurance was discussed; LPA advised applicant to review Title 22 Regulation 102417(m)(1) for additional information. Licensee states she does not have liability insurance but is considering it once licensed.

Immunization Requirement: H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Licensee submitted immunizations on 06/18/2020 via email.

Mandated Reporter Training: H&S 1596.8662: Beginning January 1, 2018, all licensed providers, applicants, directors and employees to complete training as specified on mandated reporter duties. Training is available at: www.mandatedreporterca.com Per Applicant mandated reporter training certificate is being mailed to LPA.

Infant Care: Applicant states that she will not care for infants at this time due to Baby Jackson arriving Aug. 2020. LPA advised if applicant decides to care for infants to sleep infants where they can be directly supervised at all times and advised against sleeping infants in a separate room. LPA provided the applicant with a copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. Online copy can be downloaded at:https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2020
LIC809 (FAS) - (06/04)
Page: 3 of 5
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 198400240
VISIT DATE: 06/29/2020
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*****PAGE 4*****
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

LPA advised the applicant how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov. LPA reviewed and issued the Forms/Records to Keep in Your Family Child Care Home (LIC 311D) and provided the following forms:

CHILDREN FORMS/RECORDS - Children’s files must contain the following documents/information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), Family Child Care Consumer Awareness Information (LIC 9212), Consent/Verification for Nebulizer Care (LIC 9166), California School Immunization Record, Parent Notification for Additional Children in Care (LIC 9150), Affidavit Regarding Liability Insurance (LIC 282), Acknowledgment of Receipt of Licensing Reports (LIC 9224).
FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records: As required in Title 22 Regulations 102416.1, Unusual incident/Injury Report (LIC 624B): Child Care Facility Roster (LIC 9040), Notice of Employee Rights (LIC 9052), Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108), Property Owner/Landlord Consent (LIC 9149), Property Owner/Landlord Notification Form (LIC 9149).
INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by Law to post the following:
Facility License (LIC 203), Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Notification of Parent’s Rights (PUB 394). A Notice of Site Visit (LIC 9213): Must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.
SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2020
LIC809 (FAS) - (06/04)
Page: 4 of 5
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 CENTER DR 200B
MONTEREY PARK, CA 91754
FACILITY NAME: JACKSON FAMILY CHILD CARE
FACILITY NUMBER: 198400240
VISIT DATE: 06/29/2020
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PAGE 5

OTHER INFORMATION THAT WAS DISCUSSED:
· Never Shake a Baby, Sudden Infant Death Syndrome (SIDS) and Safe Sleeping practices
· Capacity for a Large Family Child Care

Per applicant, there are no dual licenses at this address.. Applicant’s email address was obtained during this inspection. The applicant was advised that email may be public information.

Corrections: Install locks/ latches or remove hair products from restroom. Get fire extinguisher serviced.
Per Licensee all other missing documents are currently being mailed to LPA. Once all corrected LPA will submit application to LPM for final approval. Corrections due date was given for 07/06/2020 and was discussed with licensee

A Large family child care licensee will be granted upon receipt of proof of corrections for the above. Once licensed, the applicant is required to comply with the terms and limitations stated on the license. A copy of this report was reviewed and provided to the Licensee via email.

Exit interview was conducted with Shawntayzia Jackson via tele-inspection, during which appeal rights were explained. This report along with a copy of the appeal rights will be sent to the Applicant via email with a read receipt or confirmation of receipt of email, which will act as the Applicants signature.
SUPERVISOR'S NAME: Brandi VanOostenTELEPHONE: (323) 981-3365
LICENSING EVALUATOR NAME: Susann SanchezTELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2020
LIC809 (FAS) - (06/04)
Page: 5 of 5