380505746-5-9-2022-05-CC-MROZ-CE9R3A-20220509123937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380505746
Report Date: 05/09/2022
Date Signed: 05/09/2022 12:39:44 PM

Document Has Been Signed on 05/09/2022 12:39 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	JEFFERSON, GLADYS & KAREN		FACILITY NUMBER:	380505746
ADMINISTRATOR:	JEFFERSON, GLADYS		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(415) 752-3978
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94118
CAPACITY:	12	CENSUS: 3	DATE:	05/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Gladys and Karen Jefferson		TIME COMPLETED:	01:00 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	Licensing Program Analyst (LPA) Marie Rodriguez conducted an unannounced Annual inspection. LPA met with Licensees Gladys and Karen Jefferson and explained purpose of inspection. Present in home were the Licensees, Licensee's husband/father, and three preschool aged children. Licensees are operating within capacity requirements on this day. All adults living or working in the home have a criminal record clearance on file. Hours of operation are Monday to Friday from 7:00am to 6:00pm. Day Care Areas: Lower level:Living room, dining room, and bathroom. Off Limit Areas: Lower level:Remaining portions of lower level of home. Entire upper level of home. LPA toured day care areas of home with Licensees. LPA observed home to be clean and in good repair with proper temperature and ventilation. Per Licensees, there are no weapons or firearms in the home. There are no bodies of water on the premises. There is a variety of age appropriate toys and equipment in the home which are in good condition. Stairs are inaccessible to children with a child protective gate at the bottom of the stairs. Fireplace is properly barricaded. All cleaning supplies, poisons, and other chemicals are stored inaccessible to children. There is a working smoke detector and carbon monoxide detector, a fully charged fire extinguisher, and a working telephone. Five children records reviewed were complete. All children have a record of emergency identification information on file. Licensee record reviewed was complete. Licensee has a Pediatric First Aid/CPR certificate which expires April 2023. Last emergency drill was conducted in April 2022. Emergency drills are conducted at least once every six months and are properly logged. No deficiencies cited today under California Code of Regulations, Title 22, Division 12. (Continued on next page)

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: JEFFERSON, GLADYS & KAREN	FACILITY NUMBER: 380505746
	VISIT DATE: 05/09/2022

NARRATIVE

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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 (US DOJ) 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.

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.

Licensees were 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.

LPA discussed the safe sleep regulations with Licensees 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.

A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

Exit interview conducted and report was reviewed with Licensees Gladys and Karen Jefferson.

SUPERVISOR'S NAME: Daniel J Oquendo	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Marie Rodriguez	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022

LIC809 (FAS) - (06/04)

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