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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405858
Report Date: 05/10/2019
Date Signed: 05/10/2019 02:41:04 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:HACKETT, JOSEPHINEFACILITY NUMBER:
434405858
ADMINISTRATOR:HACKETT, JOSEPHINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 421-9127
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY:14CENSUS: 13DATE:
05/10/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Josephine HackettTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Mel Matos met with Josephine Hackett, Licensee, for an unannounced annual/random inspection. LPA also observed Licensee's spouse and 13 day care children (12 preschool & 1 school age) in the home during today's inspection. Days and hours of operation are Monday - Friday from 7:30 AM to 6:00 PM. The adults that reside in the home are the Licensee, Licensee's spouse, and Licensee's adult daughter. The Licensee's certifications for CPR and First Aid are current and expire on May 21, 2019. There is an active waiver in the file to allow the wood burning stove, located in the living room, not to be used during child care hours nor be hot to touch when children are present.

LPA reviewed a current Child Care Facility Roster and Fire/Disaster drill log during today's inspection. LPA reminded the Licensee to keep her roster current at all times. The last fire/disaster drill was completed on March 15, 2019. LPA reviewed thirteen children's files and observed current and updated immunization records and the Family Child Care Home Notification of Parents' Rights forms (LIC 995A) in each file.

LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe for the day care children. LPA did not observe any wall heaters inside the home. Off limit areas in the home: 3 bedrooms and living room. There are no stairs inside the home. Off limit areas outside the home: detached garage & right side section of the backyard.

LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. The Licensee states that she does not have any pets or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children.

REPORT CONTINUED ON THE FOLLOWING PAGE (PAGE #2 - REPORT DATED 05/10/2019):
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HACKETT, JOSEPHINE
FACILITY NUMBER: 434405858
VISIT DATE: 05/10/2019
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CONTINUATION OF PREVIOUS PAGE (PAGE #1 - REPORT DATED 05/10/2019):

A review of staff records on May 9, 2019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. LPA also reminded the Licensee of the applicable civil penalties for those adults who have not received fingerprint clearances, are not associated to the license and who come in contact with or provide care and supervision to the children. Penalty amounts: $100.00 per person per day, minimum of $100.00 to a maximum of $500.00 per person for an initial violation and a minimum of $100.00 to a maximum of $3000.00 per person for any subsequent violation within a 12 month period.

Supervision of children was discussed with the Licensee and she understands that she must be present in the home during day care hours and ensure that the children are supervised at all times. The Licensee understands her capacity options and she understands that she cannot have more than 14 children in the home at any time without a qualified adult assistant present. The Licensee states that she does not transport children. The Licensee states that she does not administer any medications to the day care children.

Website for provider resources & updates: http://www.cdss.ca.gov/inforesources/Community-Care/Self-Assessment-Guides-and-Key-Indicator-Tools/Quarterly-Updates

No deficiencies issued during today's inspection.

LPA conducted an exit interview with the Licensee prior to the conclusion of today's inspection and reminded the Licensee of the required "mandated reporter" training for CA Child Care Workers that all Licensees must retake every two years as of January 1, 2018. The website for the online training is:http://www.mandatedreporterca.com/training/childcare.htm

The Licensee agreed to submit copies of the Mmr, Tdap, & flu vaccine (or signed opt out form) and proof of completion of the Mandated Reporter Training for Child Care Workers to LPA Matos by Friday May 17, 2019.

A NOTICE OF SITE VISIT WAS ISSUED, POSTED NEAR THE FRONT ENTRANCE TO THE HOME, AND MUST REMAIN POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Melvin S MatosTELEPHONE: (408) 334-8554
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2019
LIC809 (FAS) - (06/04)
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