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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304313430
Report Date: 10/18/2019
Date Signed: 10/18/2019 11:53:17 AM

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:HOLLAND, JACQUELINEFACILITY NUMBER:
304313430
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:8CENSUS: 6DATE:
10/18/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jacqueline HollandTIME COMPLETED:
12:20 PM
NARRATIVE
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An unannounced Random/Annual visit was conducted today by Licensing Program Analyst (LPA), Hawkins and Licensing Program Analyst (LPA), Ryan Chan. In addition, licensee has requested to increase her capacity from small family child care home to large family child care home. Fire clearance from the City of Costa Mesa Fire Prevention was received and approved for a large family child care home. The regulations for Large Family Child Care Home were reviewed.

Upon arrival LPA was met by assistant Tiffany Wikerson and a facility tour was conducted. Present during today's inspection was assistant and 6 child care children (3 preschoolers, 3 infants). During the inspection Licensee arrived back to the home. Currently living in the home is Dennis Holland (spouse) and three minor children. The facility was clean, orderly, and was at a comfortable temperature. The licensee operates the child care Monday through Friday, 8:30am-5:30 pm. A review of staff records on this date indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions

This is a one story home with three bedrooms and one bathroom. The floor plan verified and changes made from previous visit was that bedroom #1 is made accessible to children. Licensee has designated the following areas of the home for the care and supervision of children: living room, kitchen, hallway bathroom and two bedrooms. Latches in the kitchen and bathroom appear in good working order. The off-limits areas were made inaccessible to children by means of child proof door knobs. The home has one dog, and several chickens who are kept separate from day care children with fences. Items which could pose a danger to children (detergents, cleaning compounds, and medications) were stored out of the reach of children. The licensee stated poisonous items are stored out of reach of children, and none were observed during today's inspection. The home provides safe toys, equipment, and materials. During today's inspection each child was observed to have safe, healthful and comfortable accommodations, furnishings, and equipment. There is a working carbon monoxide detector, smoke detector, and fire extinguisher in the home that meet statutory and State Fire Marshall standards. ***continued on page 2***

SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2019
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 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868

FACILITY NAME: HOLLAND, JACQUELINE
FACILITY NUMBER: 304313430
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2019
Section Cited

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102417(g)(9)(A)(1) Operation of a Family Child Care Home. All homes shall conduct fire and disaster drills at least once every six months, and document the date and time of each drill. This requirement was not met as evidenced by no record of fire drill/disaster drill log. This poses a potential Health and Safety risk to the children in care.

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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: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2019
LIC809 (FAS) - (06/04)
Page: 4 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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: HOLLAND, JACQUELINE
FACILITY NUMBER: 304313430
VISIT DATE: 10/18/2019
NARRATIVE
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Page 3

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/childganda.htm.

LPA provided licensee copy of Never Ever Shake a Baby, Safe Sleep and Lead handouts.


The licensee was also informed to visit the www.ccld.ca.gov website for Quarterly Updates. The licensee was advised on how to receive notifications for quarterly updates and provided with Child Care Advocate contact information: childcareadvocatesprogram@dss.ca.gov

The facility was not in compliance and violation of the California Code of Regulations, Title 22, Division 12 Section 102417(g)(9)(A)(1) were observed, discussed and cited at the time of the visit. (See LIC 809-D for specific deficiencies).



Prior to increase of capacity the following areas / documents must be corrected / submitted:
1. updated application LIC 279B
2. Fire/ disaster log

This file will be subject to a final in office review prior to facility capacity increase.
Inspection report review and exit interview was conducted with licensee. Notice of Site Visit was posted during the visit. Facility representative was informed that the notice of site visit must be posted for 30 consecutive days. Failure to post will result in civil penalties of $100. Appeal rights provided and explained. The licensee was provided a copy of their appeal rights (LIC 9058) and their signature on this form acknowledges receipt of these rights. First level should be sent to the regional manager to the address listed above. Licensee was informed of how/where to access regulations and forms from CCLD website: www.ccld.ca.gov.
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2019
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, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: HOLLAND, JACQUELINE
FACILITY NUMBER: 304313430
VISIT DATE: 10/18/2019
NARRATIVE
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Page 2

The licensee has a current roster of children in care. Children's records were reviewed and in compliance. The facility has not conducted an emergency drill within the past six months and there was no log available for review. Licensee stated that there are firearms present in the home and LPA verified that fire arms was made inaccessible by combination safe stored in off limit locked bedroom with ammunition locked separately.

The following were discussed: Individuals who are 18 years of age or older living or working in the home must be fingerprinted cleared prior to being present in the facility. Adults must contact a Live-Scan complete LIC 9163. If adult is fingerprinted cleared and associated to another facility, licensee must complete a Criminal Record Clearances or Exemption Transfer Request form (LIC 9182). Contact Licensing Office (714)703-2800 ask for Personnel ID#, fax Criminal Background Transfer Request form (LIC 9182 or LIC 9188) with copy of ID and Criminal Record Statement (LIC 508) to fax # (714)703-2831 prior to hiring adult.

The licensee's pediatric CPR/First Aid Certificate was verified and expires on 7/2020. Licensee have proof of immunization against TB, measles, pertussis and a written decline for influenza on file. Licensee and assistant completed Mandated Reporter Training and provided a certificate with completion date of 5/17/18.



Based on the Facility Sketch submitted, areas off limits to children and parents are: Bedroom #3, laundry room and attached garage are made inaccessible. There are child proof door knobs on all bedroom doors. Licensee was made aware that child proof door knobs are to be kept on during business hours. The licensee understands that licensing staff may have access to off-limit areas during inspection visit if necessary.

LPA advised licensee to contact licensing for any changes to hours and days of planned operation, and for any changes to facility, including on/off limit areas and change in phone number. The licensee has a cell phone that is used for child care. The licensee was reminded that if a cell phone is only used, it must remain on the premises always during hours of operation. Licensee was reminded and understands the home is to be free from smoking always. Licensee stated that she is not registered with any Foster Care agency

Continued on page 3
SUPERVISOR'S NAME: Judy HansonTELEPHONE: (714) 703-2807
LICENSING EVALUATOR NAME: Sherene HawkinsTELEPHONE: (949) 466-1624
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2019
LIC809 (FAS) - (06/04)
Page: 2 of 4