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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618616
Report Date: 02/23/2022
Date Signed: 02/23/2022 11:09:09 AM


Document Has Been Signed on 02/23/2022 11:09 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833



FACILITY NAME:SMITH, JENNIFER ANNFACILITY NUMBER:
343618616
ADMINISTRATOR:SMITH, JENNIFER ANNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 332-2563
CITY:ANTELOPESTATE: CAZIP CODE:
95843
CAPACITY:14CENSUS: 12DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Jennifer Ann SmithTIME COMPLETED:
11:30 AM
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On 2/23/22 Licensing Program Analyst (LPA) Fabiola Diaz met with licensee Jennifer Ann Smith for unannounced annual/1 year inspection. During the inspection there were 12 children at the facility. Also present was licensee's husband, daughter, and mother.

The two story home has an unfenced front yard, 4 bedrooms, 2.5 bathrooms, kitchen, living room, play room, blue table room, laundry room, preschool room, and fenced backyard. Off-limits areas in the home are: 2nd floor, detached garage, and sheds. Off-limits areas will remain inaccessible to children by closed doors and/or supervision. Licensee acknowledges that children may never enter these off-limit areas. Licensee was notified that prior to use of any off limits area, the department must be notified.

A health and safety inspection was conducted in the areas accessible to children. The house has a working telephone, fully charged fire extinguisher, smoke detector and carbon monoxide detector that meet regulations. Licensee stated there are no weapons in the home. LPA observed all the required postings. LPA advised the licensee that if there are any poisons at the home, all poisons must be locked with a key lock or combination lock. LPA observed no bodies of water on premises. LPA observed barricaded stairs. LPA observed a fire place to be barricaded.

Licensee has all of her immunization records current. Children's roster and a fire drill log were observed. Licensee's CPR/First aid card had an expiration date of 1/17/23. Mandated Reporter Training for licensee had an expiration date of 1/17/24. Licensee understands training must be complete every two years. LPA observed complete children's and assistant's files.
Report continues on 809C................
SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: SMITH, JENNIFER ANN
FACILITY NUMBER: 343618616
VISIT DATE: 02/23/2022
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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 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.

To improve the quality and value of the new inspection process, a survey will be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or tools, please send them by email to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/process.

Licensee was reminded that all adults 18 and over, 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.

Appeal Rights and Notice of Site Visit were provided. Notice of Site Visit must remain posted for 30 days. Exit interview was conducted and report was reviewed with the licensee. No deficiencies were cited on today's date.

SUPERVISOR'S NAME: Roxana SaraviaTELEPHONE: (916) 263-5715
LICENSING EVALUATOR NAME: Fabiola DiazTELEPHONE: (916) 206-9352
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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