300610155-11-19-2019-06-CC-RJCN-BJ3V3S-20191119150512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300610155
Report Date: 11/19/2019
Date Signed: 11/19/2019 03:05:25 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME:	JACOBS, SHEILA		FACILITY NUMBER:	300610155
ADMINISTRATOR:	HUTCHINSON, SHEILA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(949) 499-1178
CITY:	LAGUNA BEACH	STATE: CA	ZIP CODE:	92651
CAPACITY:	14	CENSUS: 5	DATE:	11/19/2019
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Sheila Jacobs - Licensee		TIME COMPLETED:	03:32 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	An Annual Random inspection was conducted at the facility by Licensing Program Analysts (LPAs) Chan and Nguyen. The facility is a two-story home. LPAs observed licensee and licensee’s assistant Jade Stonerock caring for 5 preschool aged children. Licensee was operating within the licensed capacity as specified on license. A review of the Facility Personnel Report Summary on this date indicates all facility residents, staff, or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. Currently there are two adults and no minor children living in the facility. During today’s inspection, LPAs and licensee toured the inside and outside areas identified in the facility sketch as accessible to child care children. Off limits areas are made inaccessible by means of child proof gates. Drawers and cabinets in the kitchen are made inaccessible by magnet locks. The home has a fireplace in the family room which is made inaccessible by a metal screen, in front of the screen is a chest. The child care area consists of the garage, family room, kitchen, side yard, den/office, and one bathroom on the first floor. There are working carbon monoxide, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. Detergents, cleaning compounds, medicines, and other items which could pose a danger if readily available to children were stored and made inaccessible to children using locks. No poisons were observed during the inspection. Licensee stated there no firearms and/or other dangerous weapons in the facility. The home has age appropriate toys for the ages served. LPAs verified there is a working telephone. There is a jacuzzi on the outdoor deck which was covered and locked on all four corners of the cover. The licensee has a current roster of children in care. Based on children’s records for children present during LPAs inspection were reviewed for a copy of the emergency information card that contains all the information specified by regulation (LIC 700) and found to be in compliance. Continued on page 2

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: JACOBS, SHEILA	FACILITY NUMBER: 300610155
	VISIT DATE: 11/19/2019

NARRATIVE

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The licensee and assistant’s Pediatric CPR/First Aid certification expires 11/2021. Beginning September 1, 2016, Health and Safety (H&S) 1597.622 states, 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. Proof of immunization against pertussis, measles, and influenza for licensee and assistant were reviewed and within compliance. Beginning March 31, 2018, H&S Code 1596.8662 requires all licensed providers and employees to complete mandated reporting training, and to renew the training every two years.

This facility provides Incidental Medical Services – IMS. LPAs reviewed storage of medication and equipment/supplies, and reviewed children’s, personnel, and administrative records. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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 licensee understands she must be present in the facility and must ensure children in care are supervised at all times and children are not to be left in parked vehicles. When the licensee is temporarily absent from the facility, arrangements must be made for a qualified substitute adult to care and supervise children while absent. The substitute adult must have the required criminal record, child abuse index clearances, immunization, Pediatric CPR/First Aid, and mandated reporter training.

CCLD website www.ccld.ca.gov was provided to licensee to access regulations, updates, and licensing forms. Licensee was advised to register through childcareadvocatesprogram@dss.ca.gov in order to receive quarterly updates. Licensee was advised of their responsibility to review the Provider Information Notices (PIN) found on the CCLD website.
A copy of the California Department of Social Services Lead Information Brochure was explained and provided to the licensee. A copy of the 2016 “A Child Care Providers Guide to Safe Sleep” was provided to the licensee.

Continued on page 3

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: JACOBS, SHEILA	FACILITY NUMBER: 300610155
	VISIT DATE: 11/19/2019

NARRATIVE

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The following electronic links were also provided:
English: https//www.cdph.ca.gov/programs/SIDS/Documents/SIDSchildcaresafesleep.pdf
AAP:https://www.healthychildren.org/English/ages-stages/baby/sleep/Pages/A-Parents-Guide-to-Safe-Sleep.aspx
NIH: https://safetosleep.nichd.nih.gov/safesleepbasics/environment/room/text_alternative
Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials

In the areas that were evaluated, no deficiencies were observed of the California Code of Regulations, Title 22, Division 12 at the time of the visit.

An exit interview conducted with licensee. Appeal Rights were explained. The Licensee was provided a copy of appeal rights (LIC 9058 01/16) and their signature on this form acknowledges receipt of these rights. All appeals must be in writing and received by the Regional Office within 15 business days. First level appeals should be sent to the regional manager to the address listed above. The Notice of Site Visit was posted and discussed as required by H&S Code Sec. 1596.817. Notice of Site Visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100.00. The Notice of Site Visit must be posted on or adjacent to the door.

SUPERVISOR'S NAME: Rina Lopez	TELEPHONE: (714) 703-2808
LICENSING EVALUATOR NAME: Ryan Joseph Chan	TELEPHONE: (714) 287-0708
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2019

LIC809 (FAS) - (06/04)

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