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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393612175
Report Date: 07/10/2023
Date Signed: 07/14/2023 01:45:25 PM


Document Has Been Signed on 07/14/2023 01:45 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:JACKSON, KAREN ANNFACILITY NUMBER:
393612175
ADMINISTRATOR:JACKSON, KAREN ANNFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 469-7381
CITY:STOCKTONSTATE: CAZIP CODE:
95204
CAPACITY:14CENSUS: 2DATE:
07/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Karen Ann JacksonTIME COMPLETED:
02:00 PM
NARRATIVE
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On July 14th, 2023, at 11:30 am, Licensing Program Analyst (LPA), David Nguyen met with Licensee, Karen Ann Jackson for the purpose of an unannounced annual inspection. The purpose of the unannounced annual inspection was explained. LPA was granted for entry into the facility by Licensee. There were two (2) children present at the time of inspection. Licensee's operating hours are Monday through Friday from 6:00 AM. to 6:00 PM. Meals—breakfast, AM snack, lunch, and PM snack—were provided to daycare children. Filtered water from dispenser on the refrigerator was provided for drinking water. LPA verified the annual fees are current.

Licensee 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.

A health and safety inspection was conducted in all areas accessible to children. The one-story home has 2 bedrooms and 2 bathrooms. The off-limits area in the home include all the bedrooms, the garage, the bathroom in the hallway, and the dog area. Off-limits areas will remain inaccessible to children by baby gate and SUPERVISION. LPA observed the required postings and a working phone. 3B40BC fire extinguisher meets regulations. LPA observed smoke and carbon monoxide detectors, and verified they were both functional. LPA toured the kitchen area and verified knives and cleaners were inaccessible to children in care. Licensee stated there are no weapons in the home. There are no bodies of water on the premises. LPA observed a restroom and verified that hazardous and toxic items were inaccessible to children in care.



Report continues on 809-C.
SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2023
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: JACKSON, KAREN ANN
FACILITY NUMBER: 393612175
VISIT DATE: 07/10/2023
NARRATIVE
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(Page 2)

Children's files were reviewed. Emergency information and required immunization records were on file. LPA observed a current roster and documentation that a fire drill is conducted at least once every six months. The last fire drill was conducted and logged on 7/6/2023. Licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are unavailable in the facility file. Current in-person EMSA pediatric CPR and First Aid certification was verified and expired 9/2018. Licensee has a current Mandated Reporter Training Certificate that expires 7/2025.

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.

This provider is not currently providing IMS services to children in care. Incidental Medical Services (IMS) policy was discussed.

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



Report continues on LIC809-C....(Page 3)
SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: JACKSON, KAREN ANN
FACILITY NUMBER: 393612175
VISIT DATE: 07/10/2023
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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/inspection-process

Exit interview conducted and report was reviewed with the licensee. A Notice of Site Visit was given and must remain posted for 30 days for parental review. Licensee was encouraged to visit the Department website at WWW.CCLD.CA.GOV for childcare updates, current forms, legislation and regulation information. A copy of this report will remain on file for a period of three years for public review upon request. Licensee's signature on this form acknowledges receipt of this form. A notice of site visit was provided and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

In the areas that were evaluated, two (2) Type B deficiencies were cited during today’s inspection.
SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/14/2023 01:45 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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: JACKSON, KAREN ANN
FACILITY NUMBER: 393612175

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102416(c)
Personnel Requirements
(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee agreed to enroll in Pediatric CPR and First Aid class and submit to LPA a copy of Pediatric CPR and First Aid class registration to LPA by plan of correction date, 8/28/2023. Licensee also agreed to submit a copy of Certificate of Completion for Pediatric CPR and First Aid to LPA by plan of correction date, 8/28/2023.
Type B
Section Cited
HSC
1597.622(a)(1)
General Provisions and Definitions
(1) Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. Each employee and volunteer shall receive an influenza vaccination between August 1 and December 1 of each year.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Licensee agreed to contact her health care provider and obtain proofs of required vaccines by plan of correction date, 8/28/2023. Licensee also agreed to submit a copy of immunization record for required vaccines to LPA by plan of correction date, 8/28/2023.
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: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 07/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2023
LIC809 (FAS) - (06/04)
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