<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434411757
Report Date: 08/11/2022
Date Signed: 08/11/2022 02:31:48 PM


Document Has Been Signed on 08/11/2022 02:31 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
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: 11DATE:
08/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:58 PM
MET WITH:Donna JordanTIME COMPLETED:
03:00 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
Licensing Program Analyst (LPA) Janette Cruz met with Donna Jordan, Licensee, for an unannounced Required – 1 year annual inspection. LPA was granted access to the home by the Licensee. LPA also observed, Licensee's adult assistant, Daisy Almejo and 11 preschool children present in the home during today's inspection. LPA observed the required postings, including the facility license by the entry area of the home. Days and hours of operations are Monday - Friday from 7:30 AM to 5:30 PM. The Licensee, Licensee's spouse, Timothy Jordan, Licensee's daughter, Ashleigh Marie Jordan and son, Curtis James Jordan, are the adults residing in the home. Licensee and her adult assistant have Pediatric CPR and First Aid cards with an expiration date of 08/2023.

LPA reviewed the Child Care Facility Roster and Fire/Disaster drill log during today's inspection. The last fire/disaster drill was completed on 3/06/2022. Licensee does not carry an active Child Care Liability Insurance. Licensee has the required vaccinations (MMR, Tdap, & flu). LPA reviewed Licensee's and her assistant's Mandated Reporter Training credentials. LPA reviewed ten children's files which were complete with the required forms.

LPA discussed the safe sleep regulations with the 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 the 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.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: JORDAN, DONNA
FACILITY NUMBER: 434411757
VISIT DATE: 08/11/2022
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
26
27
28
29
30
31
32
LPA toured the indoor and outdoor areas of the home during today's inspection. Licensee has a working telephone in the home, (408) 927-7357. LPA observed sufficient materials, toys, and play equipment for the day care children. Licensee states that a child
will be isolated in the office area of the home if necessary due to illness or communicable disease.

LPA observed the home that is clean, orderly, and safe for the day care children. LPA observed a barricaded fireplace and no open face heaters in the home. Off limit areas inside the home : master's bedroom with bathroom, two bedrooms and garage. Off limit areas outside the of the home: left and right side of the backyard with two locked storage sheds. LPA observed a fenced backyard.

LPA observed a fully charged 3A40BC fire extinguisher and working smoke/carbon monoxide detectors. The Licensee observed that Licensee has two pet dogs (Dobberman and Labrador) that are kept inaccessible to children in care. Licensee states she has no weapons in the home. All other detergents, cleaning compounds, medications, and other similar items are inaccessible to children. All poisons are stored in the locked shed and garage. The Licensee states that she does not administer medication to the day care children at this time.

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

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.
SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/11/2022 02:31 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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131


FACILITY NAME: JORDAN, DONNA
FACILITY NUMBER: 434411757

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above. Licensee and her adult assistant did not have an current Mandated Reporter Training Certificate upon inspection which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2022
Plan of Correction
1
2
3
4
Licensee will submit to LPA current Mandated Reporter Training Certificate for herself and adult assistant by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: JORDAN, DONNA
FACILITY NUMBER: 434411757
VISIT DATE: 08/11/2022
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
26
27
28
29
30
31
32
Supervision of children was discussed with 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 that she cannot have more than 14 children in the home at any time. Licensee states that she does not transport any day care children. The Licensee understands that children shall not be left unattended in parked vehicles and that car seats shall only be used for transportation and shall not be used for sleeping.

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/process.


Based on staff interview conducted, Licensee has not had an experience of caring for a child with food allergies needing modified diet or medical attention. LPA provided Licensee with website resources on managing food allergies at school and handling medical emergencies related to food allergies.

CDC Managing Food Allergies at School
https://www.cdc.gov/healthyschools/foodallergies/index.htm
American Academy of Pediatrics Healthy Children Medical Emergencies
https://www.healthychildren.org/English/health-issues/injuries-emergencies/Pages/When-to-Call-Emergency-Medical-Services-EMS.aspx

Exit interview conducted and report was reviewed with the Licensee, Donna, Jordan. A deficiency was issued during today's inspection.

A Notice of Site Visit was given and must remain posted for 30 days.

SUPERVISOR'S NAME: Diana StephensonTELEPHONE: (408) 324-2128
LICENSING EVALUATOR NAME: Janette CruzTELEPHONE: (408) 334-8312
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4