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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393612175
Report Date: 06/13/2024
Date Signed: 06/13/2024 04:00:54 PM


Document Has Been Signed on 06/13/2024 04:00 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: 0DATE:
06/13/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jackson, Karen AnnTIME COMPLETED:
04:15 PM
NARRATIVE
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On June 13th, 2024, at 2:00 PM, Licensing Program Analyst (LPA), David Nguyen and 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 zero (0) children present at the time of inspection. Licensee’s husband and biological granddaughter were 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 reviewed annual license fees with licensee and 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, 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 LIC809-C....(Page 2)

SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 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: 06/13/2024
NARRATIVE
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(Page 2)
A health and safety inspection was conducted in all areas accessible to children. The detached one-story and single-family home consists of three (3) bedrooms and two (2) bathrooms. The off-limits areas in the home include all the bedrooms, the garage, the bathroom in the hallway, and the dog area. The off-limits areas will remain inaccessible to children by baby gates 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. Licensee stated that none of her direct neighbors have in-the-ground pool or above-the-ground pool. LPA observed a restroom and verified that hazardous and toxic items were inaccessible to children in care. Licensee stated that her FCCH houses three (3) indoor and outdoor dogs and two (2) outdoor cats.

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 6/7/2024. Licensee's immunization records for measles (MMR), pertussis (Tdap), and the flu are available in the facility file. Current in-person EMSA pediatric CPR and First Aid certification was verified and expires on 8/5/2025. Mandated Reporter Training Certification was verified and expires on 7/11/2025.

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.
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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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: 06/13/2024
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(Page 3)
LPA discussed the Year-Round/Daily Reminder of Water Safety Requirements and Measures with licensee. LPA provided licensee the PIN 23-17-CCLD, the Year-Round and Daily Reminder of Water Safety Requirements and Measures. LPA discussed with Licensee the importance of checking for bodies of water on the premises daily prior to children’s arrival to improve children’s safety.

This provider is not currently providing IMS services to children in care. 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/.

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.

During the exit interview, the LICENSEE, Karen Ann Jackson confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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.

Report continues on LIC809-C...(Page 4)

SUPERVISOR'S NAME: Chayntel HunterTELEPHONE: (916) 917-8620
LICENSING EVALUATOR NAME: David NguyenTELEPHONE: (916) 263-5744
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 3 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: 06/13/2024
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(Page 4)
Exit interview conducted and report was reviewed with the licensee, Karen Ann Jackson. 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, no 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: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4