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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411757
Report Date: 08/29/2019
Date Signed: 08/29/2019 03:56:55 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:JORDAN, DONNAFACILITY NUMBER:
434411757
ADMINISTRATOR:JORDAN, DONNAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 927-7357
CITY:SAN JOSESTATE: CAZIP CODE:
95120
CAPACITY:14CENSUS: 0DATE:
08/29/2019
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jordan, DonnaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Almaraz, Araceli conducted an annual random inspection. LPA Almaraz met with Licensee, Jordan, Donna and explained the nature of today's inspection. Present during the inspection was the licensee Jordan and Assistant Almejo, Daisy. There were no children present. Licensee stated the day care is closed from 08/26/2019 to 08/30/2019, in order to prepare for the new school year. The day care will resume on 09/03/2019. The hours of operation of the day-care are 7:30 AM to 5:30 PM, Monday through Friday. There are four adults residing in the home; Licensee Jordan, spouse Jordan Timothy, daughter Jordan Ashleigh and son Jordan, Curtis. LIcensee Jordan, Assistant Almejo and Volunteer McDonald, Carol have CPR and First Aid, which have an expiration date of 06/01/2021.

LPA Almaraz observed that Licensee Jordan has record of MMR & Tdap vaccinations as well the flu vaccine. LPA Almaraz observed Assistant Almejo has record of MMR & Tdap vaccinations and opt out of the flu vaccine. LPA Almaraz reviewed two 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 Almaraz observed a current roster. Licensee Jordan has no day care insurance. Licensee Jordan completed Mandated Reporter Training on 04/18/2018, licensee Jordan understands training is to be completed every two years.

LPA Almaraz observed a working smoke/carbon monoxide detector, 2A10BC fire extinguisher. LPA Almaraz did not observe any heaters in the home. LPA Almaraz observed a barricaded fireplace. LPA Almaraz observed a current fire disaster/earthquake drills last log 05/28/2019.
Report Continued on Page 2*****
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019
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 3
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: JORDAN, DONNA
FACILITY NUMBER: 434411757
VISIT DATE: 08/29/2019
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LPA Almaraz inspected the indoor and outdoor areas of the home today. Off limit areas in the home are as follows; Master bathroom/bedroom, two bedrooms, laundry room and garage. Licensee Jordan states this area is normally gated off to prevent access to the children in care. Off limit areas outside the home are as follows: The right side of the yard and left side of the yard. Both areas are gated off preventing access to the children in care. The front yard is safety compliant and backyard is fully fenced. There is one storage shed in the accessible area, it has a lock on it, LPA Almaraz observed the items inside are safety compliant. Licensee Jordan states that there are no weapons in the home. LPA Almaraz observed one turtle tank, covered and preventing accessibility to the children in care. No other bodies of water such as wading pools, ponds or swimming pools were observed. Medication, cleaning products and similar items are stored inaccessible to children. Poisons must be locked. There are three pets in the home.

Supervision of the children was discussed; the Licensee Jordan understands a cleared adult must be present in the home during day care hours. Licensees Jordan understand that the children must be supervised at all times. Licensee Jordan understands the capacity options and ratio requirements. Licensee Jordan understands not to leave children in the car unattended. Licensee Jordan states that there is no transporting of children currently.

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 Continued on Page 3*****

SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3
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: JORDAN, DONNA
FACILITY NUMBER: 434411757
VISIT DATE: 08/29/2019
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A review of staff records on 08/202019 indicates that all Facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions.

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

There are no deficiencies during today’s inspection.

NOTICE OF SITE VISIT WAS ISSUED, AND MUST BE POSTED FOR 30 CONSECUTIVE DAYS.
SUPERVISOR'S NAME: Mary SeguraTELEPHONE: (408) 324-2152
LICENSING EVALUATOR NAME: Araceli AlmarazTELEPHONE: (408) 334-8551
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3