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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 483001109
Report Date: 05/11/2023
Date Signed: 05/11/2023 10:17:42 AM


Document Has Been Signed on 05/11/2023 10:17 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:SMITH, JEANETTE FAMILY CHILD CARE HOMEFACILITY NUMBER:
483001109
ADMINISTRATOR:SMITH, JEANETTEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 422-3182
CITY:FAIRFIELDSTATE: CAZIP CODE:
94533
CAPACITY:14CENSUS: 5DATE:
05/11/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Licensee Jeanette SmithTIME COMPLETED:
10:25 AM
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Licensing Program Analyst ( LPA) Elpidia Hernandez Torres, arrived to the facility to conduct a Plan of Correction visit. LPA was previously at the facility on 04/24/2023 for an inspection were the licensee was cited deficiencies for: children missing immunization record and blue CDPH 286, Children's records were incomplete, facility roster was incomplete and infant missing sleeping plan LIC 9227.

LPA conducted record review for children C1-C6 at 09:25AM, all children who required immunizations had blue CDPH 286 on file. Children's records were complete with required emergency forms. Infant in care had LIC 9227 and sleep log on file. Licensee emailed AB 1207 mandated reporter to LPA on 05/03/2023, the certificates expire on 05/01/2025 for licensee and assistant. The licensee has registered for EMSA pediatric CPR 1st aid and will complete training by 05/27/2023. The facility roster was updated with all children enrolled and contain required information.

All deficiencies cited on 04/24/2023 have been cleared during todays visit. No deficiencies were cited. Notice of site visit shall be posted for 30 days.
SUPERVISOR'S NAME: Leslie LeporiTELEPHONE: (707) 588-5060
LICENSING EVALUATOR NAME: Elpidia Hernandez TorresTELEPHONE: (707) 771-5568
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
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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