198400240-8-19-2021-54-CC-SSAZ-C62QMU-20210819121806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198400240
Report Date: 08/19/2021
Date Signed: 08/19/2021 12:18:15 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 CARE		FACILITY NUMBER:	198400240
ADMINISTRATOR:	SHAWNTAYZIA A. JACKSON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(562) 556-3416
CITY:	CARSON	STATE: CA	ZIP CODE:	90746
CAPACITY:	14	CENSUS: 9	DATE:	08/19/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Shawntayzia Jackson, Licensee		TIME COMPLETED:	12:37 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) Susann Sanchez conducted a required 1 year inspection. LPA met with Shawntayzia Jackson, Licensee who guided analyst on a tour of the facility. Per Licensees, family members residing in the home are 2 adults. Per licensees, operation hours will be Monday to Friday, 6:00AM to 6:00PM. Licensees states that they will care for children 1 years old- 12 years of age. The FCCH roster was reviewed and is current. There are children 9 children were present during inspection which 1 were infants. 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 Licensee, the children will use the restroom in the hallway, dining area (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. Based on the Facility Sketch submitted, areas off limits to children and parents are: All bedrooms, kitchen, living room, garage and front yard. LPA observed all off- limit area are locked and there is a gate blocking the kitchen. The licensee understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 198400240
	VISIT DATE: 08/19/2021

NARRATIVE

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OUTDOOR PLAY AREA
The children use the back yard for outdoor play, which was observed to be fenced. Licensee states that children will be physically and visually supervised at all times.

PETS: Per licensee, there is a puppy.
BODIES of WATER: Per licensee, there are no bodies of water on the premises.
FIREARMS/WEAPONS: Per licensee, there are no fire arms or weapons on the premises.
There are toys available for children. The licensee states that they provide food for children in care.

The value on the 2A10BC fire extinguisher has not been serviced since 04/08/2019, as indicated on the service receipt. Smoke and carbon monoxide detectors were tested and operable. The licensee has completed the required Health and Safety Training, Nutrition Training and Pediatric First Aid and CPR. Licensee CPR & First Aid expires on 03/21/2023. There are first aid supplies available. The last drill was conducted on 08/19/2021.

Infant Care: Licensee is caring for infants but will not care for infants under 12 months. LPA advised to sleep infants where they can be directly supervised at all times and advised against sleeping infants in a separate room. The licensee states the following as a supervision plan for infants: Licensees states that infants will sleep in the day care room. LPA advised Licensee physically check on sleeping infants every 15 minutes and document whether there is labored breathing, signs of distress, and sleep position (on their backs) . Licensee has a camera in the infant nap room. LPA provided the applicant with copy of the Child Care Provider’s Guide to Safe Sleep, by American Academy of Pediatrics. LPA went over in detailed PIN 20-24. Online copy can be downloaded a https://www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf

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

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 198400240
	VISIT DATE: 08/19/2021

NARRATIVE

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LPA advised the licensee how to access forms, regulations and quarterly updates on the Child Care Licensing website at: www.ccld.ca.gov

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

A copy of the LIC 9213 was given to licensee—Notice of Site Visit. 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.

SUPERVISOR'S NAME: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

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, 1000 CORPORATE CENTER DR 200B
MONTEREY PARK, CA 91754

FACILITY NAME: JACKSON FAMILY CHILD CARE	FACILITY NUMBER: 198400240
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/02/2021 Section Cited	1 2 3 4 5 6 7	Operation of a Family Child Care Home The home shall contain a fire extinguisher and smoke detector device which meet standards established by the State Fire Marshal. This requirement is not met as evidenced by LPAs observed no proof of fire extinguisher service tag or purchase receipt within one year. 04/08/2019, was the last time
	8 9 10 11 12 13 14	fire extinguisher was service as stated on the service tag. This poses a potential risk to the health and safety of children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Valarie Cook	TELEPHONE: (323) 513-3858
LICENSING EVALUATOR NAME: Susann Sanchez	TELEPHONE: (323) 981-3366
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021

LIC809 (FAS) - (06/04)

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