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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618563
Report Date: 05/12/2023
Date Signed: 05/12/2023 12:21:28 PM


Document Has Been Signed on 05/12/2023 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:JARVIS, TINAFACILITY NUMBER:
343618563
ADMINISTRATOR:JARVIS, TINAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 334-1595
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:14CENSUS: 4DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:licensee, Tina JarvisTIME COMPLETED:
12:40 PM
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An unannounced annual/random inspection is made today by LPA's Owens and Barragan. Present at time of inspection were licensee, husband and 4 day care children. Ages of children present were 9 months, 1and 1/2, 2 and 4 years old.

A tour of the home, inside and outside, as shown on the facility sketch is conducted. Licensee states there are no weapons or firearms in the home. There is no spas or pools accessible to children. LPA observed poisons, cleaning compound's, medications and other hazardous items are inaccessible to children. However, LPA's observed that the Licensee had 2 knifes in the drawer that were in hands reach of the clients and the drawers weren't locked. Additionally, there was a knife with the sharp side exposed to clients in the sink. There was a fireplace; however, it was fences. Fire extinguisher, Carbon Monoxide Detector and Smoke Detector meets regulations. Currently, licensee does have 2 dogs and 1 cat. She chooses to allow the cat to have access to day care children and she is aware that she is responsible for child safety around pets at all times. The Licensee stated that the dogs are not around the children. There are no stairs in the home. Toys and play equipment that were observed appear to be safe. There is a working telephone. Adequate supervision is being provided during this inspection. Children are supervised when outside in any unfenced play area. There was one infant under 12 months old present; 1 sleeping plan was reviewed.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Continued on next page.

SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-5714
LICENSING EVALUATOR NAME: Eduardo BarraganTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: JARVIS, TINA
FACILITY NUMBER: 343618563
VISIT DATE: 05/12/2023
NARRATIVE
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The capacity as specified on the license is being maintained. All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home. Licensee, Kelly Weber, was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Pediatric CPR/FA is current with expiration date of 11/2023. A child roster is maintained. Fire and disaster drills are conducted every six months and documented. Children records reviewed.

LPA observed proof that licensee and staff/ volunteers have met the requirements of SB 792.

LPA observed that all staff has completed the required mandated reporter training (AB 1207) at website: www.mandatedreporterca.com

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. No children currently on medication.



Off-limit rooms are: All bedrooms including the Master bedroom, guess room shed, in the backyard the left side of the house (when looking directly at the house) and the front yard.. Licensee acknowledges that children may never enter these off-limit areas. Observed tool shed in backyard and it locked by key lock. During the exit interview, LPA discussed AB 633, Parent Notification Requirements, and the posting of licensing inspection notices and reports. Hours of operation are 7:30 AM to 6:30 PM; Monday thru Friday and other hours as arranged. Licensee states she does transport children. continued on next page.
SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-5714
LICENSING EVALUATOR NAME: Eduardo BarraganTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
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
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: JARVIS, TINA
FACILITY NUMBER: 343618563
VISIT DATE: 05/12/2023
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LPA provided the Community Care Licensing website www.ccld.ca.gov, so the licensee can obtain updated licensing information, new regulations and access forms. LPA advised licensee of their responsibility to stay current in regards to new regulations. LPA also included the email address for the children's advocacy program to stay current on new laws childcareadvocatesprogram@dss.ca.gov.

To receive important licensed- related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.


Per Chapter 3, Division 12, Title 22 of the California Code of Regulations, NO deficiencies are observed today.

Exit interview conducted and report was reviewed with the licensee, Tina Jarvis
A notice of site visit was given and posted for 30 days.

One citation was administered during todays inspection.

THIS REPORT SHALL BE MADE AVAILABLE TO THE PUBLIC UPON REQUEST. .
SUPERVISOR'S NAME: Natalie DunawayTELEPHONE: (916) 263-5714
LICENSING EVALUATOR NAME: Eduardo BarraganTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/12/2023 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVER CITY (SACTO)CC, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833


FACILITY NAME: JARVIS, TINA
FACILITY NUMBER: 343618563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(4)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (4) Poisons, detergents, cleaning compounds, medicines, firearms and other items which could pose a danger if readily available to children shall be stored where they are inaccessible to children. (A) Storage areas for poisons, firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA's observed that the Licensee had 2 knifes in the drawer that were in hands reach of the clients and the drawers weren't locked. Additionally, there was a knife with the sharp side exposed to clients in the sink, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/12/2023
Plan of Correction
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The Licensee stated that she will ensure that the knifes go in a cabinet that is higher up and not in the clients arms reach. The Licensee stated that she will provide pictures to LPA Barragan of corrections. The email: Eduardo.barragan@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Natalie DunawayTELEPHONE: (916) 263-5714
LICENSING EVALUATOR NAME: Eduardo BarraganTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
LIC809 (FAS) - (06/04)
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