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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 367700002
Report Date: 07/05/2023
Date Signed: 07/05/2023 09:59:36 AM


Document Has Been Signed on 07/05/2023 09:59 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551



FACILITY NAME:JACKSON FAMILY CHILD CAREFACILITY NUMBER:
367700002
ADMINISTRATOR:OTECHIA JACKSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(909) 246-4174
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY:14CENSUS: 10DATE:
07/05/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Otechia JacksonTIME COMPLETED:
10:30 AM
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On 07/5/23, Licensing Program Analysts (LPAs) Carol Heath conducted a subsequent annual Inspection for the purpose of amending the Facility Evaluation Report LIC 809-D dated 6/12/2023 to correct the information provided. During today’s visit, there are 10 children with the licensee and her son (16 years old).

On 6/12/2023, Licensing Program Analyst (LPA) Carol Heath met with Licensee Otechia Jackson to conduct an unannounced Annual inspection. During the 6/12/2023 inspection, LPA observed, interviewed, and reviewed the file, the licensee allowed staff #1 to provide care and supervision to children without a criminal record clearance for more than 5 days. According to the licensee, the individual #1 did start with his exemption process. However, the assistant and the licensee did not follow through the process.

An exit interview was conducted, and a copy of this report, notice of the site visit, and appeal rights were provided to the facility.

SUPERVISOR'S NAME: Claretta YatesTELEPHONE: (661) 202-3407
LICENSING EVALUATOR NAME: Carol HeathTELEPHONE: (661) 202-3709
LICENSING EVALUATOR SIGNATURE:
DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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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