394500306-4-13-2021-53-CC-ASRN-C22PNW-20210413112836

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 394500306
Report Date: 04/12/2021
Date Signed: 04/13/2021 11:28:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME:	JACKSON-GONZALEZ, SHANKELA		FACILITY NUMBER:	394500306
ADMINISTRATOR:	JACKSON-GONZALEZ, SHANKELA		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(209) 932-9916
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95212
CAPACITY:	14	CENSUS: 0	DATE:	04/12/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Shankela Jackson		TIME COMPLETED:	02:45 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	Note-Due to State of Emergency Order due to COVID-19 the inspection was conducted virtually via Facetime. The report will be emailed to applicant for signatures and documented in 812. On April 12th, 2021 at 12:40pm, Licensing Program Analyst (LPA) Aruna Sridharan conducted tele-inspection on Facetime with applicant Shankela Jackson. LPA informed the purpose of the inspection; applicant is requesting a large family home child care license. LPA toured the single story home with four bedrooms and two bathrooms. All adults have a criminal record clearance. The facility will operate Monday-Friday for 24 hours. The fire clearance was issued on 02/05/2021. A health and safety inspection was conducted inside and out. The home has four bedrooms, two bathrooms, a living room, dinning area, kitchen, garage, fenced front yard and backyard. The off-limits areas in the home will be all bedrooms, laundry and garage. Off-limit areas will remain inaccessible to children by gates and/or supervision and understands that children may never enter these off-limit areas. The applicant stated that there are no weapons in the home. There are no bodies of water on the property. The fireplace in the living room is inoperable. The 2A-10-B-C fire extinguisher is in the kitchen. LPA tested the smoke alarm and Carbon Monoxide and meet regulations. First aid kit is in the living room entryway. Toxic and hazardous items are inaccessible to children. Medications are kept in the upper cabinet in kitchen inaccessible to children. Cleaning supplies are kept in upper cabinet in the kitchen. Applicant rents the home and LPA observed the agreement. Applicant has completed the 16-hour Preventative health training with the Lead Poison Prevention module and CPR/First Aid that expires on 06/2021. Applicant has completed the required AB1207 Mandated Reporter training that expires on 12/2021. Applicant understands that the training must be completed once every two years. Report continues on 809C.....

SUPERVISOR'S NAME: Sharon Ogbodo	TELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Aruna Sridharan	TELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: JACKSON-GONZALEZ, SHANKELA	FACILITY NUMBER: 394500306
	VISIT DATE: 04/12/2021

NARRATIVE

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LPA provided blank forms required for children's records, including immunization cards, a SIDS brochure and Never Shake a Baby pamphlet. Applicant stated that Safe Sleep Practices and Regulations are understood. She stated she understand infants cannot sleep in car seats, swings or other items not intended for sleeping. LPA advised applicant that baby walkers, bouncers, jumpers, and similar items are not allowed in Family Child Care Homes (FCCH).

Applicant understands that children’s records are to be maintained according to Title 22 regulations, and be accessible to licensing for up to three years. Applicant understands that her License, Emergency Disaster Plan, Earthquake Preparedness Checklist and the Parents Rights Poster must be posted in the home. Applicant has posted the required documents.

Applicant does not plan on providing transportation. Applicant understands that a current roster must be maintained and it was understood that fire drills (by checking fire extinguisher and smoke detector) will be conducted and documented at least every six months, LPA provided applicant with a Fire Drill Log.

LPA explained the Inspection Authority, Zero Tolerance and Immediate Civil Penalty regulation, deficiencies and citations with the applicant. LPA explained Unusual Incident Reporting and the requirement to notify the department within 24 hours of an incident and the requirement to follow up with the written report LIC 624 within seven days to remain in compliance.

LPA discussed the Immunization Regulations SB 792, the requirement that all individuals working or volunteering at a licensed Family Child Care Home(FCCH) must have vaccinations against, Pertussis, Measles and Influenza. Proof of required vaccines have been obtained from applicant.

Applicant understands that anyone living or working in the home, eighteen years of age or older must obtain fingerprint clearance PRIOR to living or working in the home. Applicant understands that if anyone else works with the children, they must also obtain the following: EMSA approved or American Red Cross or American Heart Association CPR and first aid training, immunization for TB, Measles, Pertussis and Influenza, and complete AB1207 Mandated Reporter Training.
Report continues on 809C......

SUPERVISOR'S NAME: Sharon Ogbodo	TELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Aruna Sridharan	TELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021

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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833

FACILITY NAME: JACKSON-GONZALEZ, SHANKELA	FACILITY NUMBER: 394500306
	VISIT DATE: 04/12/2021

NARRATIVE

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Applicant understands that if any structural changes are made to the home; licensing must be notified prior to construction. Applicant understands that if she wants to make any off-limit areas an ON-limits for children, she must notify licensing and LPA must do an inspection BEFORE children are allowed in the areas.
Applicant understands that her FCCH license is not transferable, and once licensed, applicant must live in the home and be present for 80% of the operating hours. Applicant understands children must have 100% supervision in unfenced areas. LPA explained to applicant that if she moves and wants to continue to provide care, she must submit a change of location application and have the new home inspected again before providing care.
The applicant plans on providing IMS care. 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
This facility evaluation report was reviewed and discussed with the applicant. Records, postings and reporting requirements were discussed. Applicant was encouraged to visit the department website at WWW.CCLD.CA.GOV for information regarding child care updates, forms, regulations and legislation pertaining to family child care homes.
LPA provided COVID-19 resources and updated regarding the CDC and state guidelines in following the Covid pandemic safety precautions while providing care for children. LPA also discussed the Self Assessment checklist with licensee.

As of 04/12/2021 the facility is approved for a Large Family Child Care Home licensed to serve a maximum capacity of 14 with the following capacity; 14 children, two (2) of which must be at least 6 years of age and no more than three (3) may be infants; or 12 children, four (4) of which may be infants. Infants are children under the age of 2. Licensee understands when not using an assistant the capacity reverts back to the small family day care home license capacity. six children with no more than three infants or four infants only OR a capacity of eight children with no more than two infants, one child must be in Transitional Kindergarten/Elementary School and one child must be at least six years old. The licensee's children under the age of 10 will count in the ratios.

SUPERVISOR'S NAME: Sharon Ogbodo	TELEPHONE: (916) 263-5721
LICENSING EVALUATOR NAME: Aruna Sridharan	TELEPHONE: (916) 917-9273
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2021

LIC809 (FAS) - (06/04)

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