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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393600292
Report Date: 07/13/2023
Date Signed: 07/13/2023 02:49:57 PM

Document Has Been Signed on 07/13/2023 02:49 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ADDI, JACQUELINEFACILITY NUMBER:
393600292
ADMINISTRATOR:ADDI, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 403-1904
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 14TOTAL ENROLLED CHILDREN: 8CENSUS: 7DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Jacqueline AddiTIME COMPLETED:
03:10 PM
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On 07/13/23, Licensing Program Analyst (LPA) Elvira Sierra met with the licensee, Jacqueline Addi for the purpose of an unannounced annual inspection. Present in the facility were Licensee and Licensee’s assistant caring for seven daycare children. All individuals subject to criminal background review have obtained a criminal record clearance. Facility hours of operation are M-F 07:00 am to 05:00pm.
A health and safety inspection was conducted in all areas accessible to children. Off-limits areas include; Garage and all bedrooms. Home is clean and appropriately ventilated. LPA observed the required postings, a working phone, 2A10BC fire extinguisher, and functioning smoke and carbon monoxide detectors. Age-appropriate toys and reading material were observed accessible to children. Licensee stated there are no weapons in the home. Home has a swimming pool that is enclosed according to Title 22 regulations. Toxic and hazardous items are inaccessible to children. The fireplace in the home is appropriately barricaded to prevent access by children and outdoor play space is fenced for supervision. Licensee stated she provides meals.
5 children’s files were reviewed and are complete containing all require forms. LPA observed a current roster and fire drills are conducted at least once every six months. Last fire drill was conducted on 05/13/23. The licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. LPA observed that Licensee’s assistant also have the required immunization on file at the facility. Current in person EMSA CPR and First Aid certification was verified. Licensee CPR expires on 01/28/25 and Licensee’s assistant (husband) expires on 01/28/25. Licensee’s AB 1207 Mandated Reporter Training was verified and expires on 10/17/24.
Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated. Report continues on subsequent page 809C--
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ADDI, JACQUELINE
FACILITY NUMBER: 393600292
VISIT DATE: 07/13/2023
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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: https://www.ada.gov/resources/child-care-centers/.

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.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. 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
Entrance Checklist was provided. Exit interview conducted and report was reviewed with the licensee, Jacqueline Addi. A notice of site visit was given to licensee and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.
SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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