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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 515407156
Report Date: 01/29/2020
Date Signed: 01/29/2020 12:18:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., SUITE 170
CHICO, CA 95926
FACILITY NAME:JACOBS, TERESA FAMILY CHILD CARE HOMEFACILITY NUMBER:
515407156
ADMINISTRATOR:JACOBS, TERESAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 730-0640
CITY:YUBA CITYSTATE: CAZIP CODE:
95993
CAPACITY:14CENSUS: 8DATE:
01/29/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Dominic JacobsTIME COMPLETED:
12:20 PM
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An inspection was made to the facility by Licensing Program Analyst (LPA) Martinez. A review of staff records on 1/27/20 indicates that all facility staff or other individuals who require caregiver background checks have received criminal record and child abuse index clearances or exemptions. During today's visit the licensee and normal assistant had to leave to an appointment and the children were being watched by the two assistants. There are currently 3 adults living in the home. During today’s inspection the home and grounds were toured. The two assistants were supervising 8 children, and operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicle. The facility’s operating hours are 7AM to 5:30PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The off-limits areas of the home are the two bedrooms, garage, and kitchen area, and were made inaccessible by gate. The home was observed to be clean and orderly, and was at a comfortable indoor temperature. There were safe toys and equipment available for children. The licensee stated there is a working telephone in the home. The licensee’s pediatric CPR and First Aid certifications were reviewed, and a copy will be mailed to the department. Items which could pose a danger to children were observed to be stored out of the reach of children. Poisons were locked in the garage. The fireplace has been made inaccessible with a gate preventing access to the area. The LPA observed a working smoke detector, carbon monoxide detector and fire extinguisher, rated at least 2A10BC, in the home. The roster of children in care was reviewed and was current. The licensee has conducted an emergency drill within the past six months. The licensee stated there are no firearms and/or other dangerous weapons in the home and none were observed during today's inspection. The children use the local park as the outdoor play area and the licensee is aware full supervision is required. There is a in ground pool in the back yard. The pool is fully fenced with water safety fence on three sides and the perimeter fence. Eight children's records were reviewed at 12:00PM; current immunization's and Notification of Parent’s Rights forms were on file. The licensee is not providing Incidental Medical Services (IMS) to children in care. The Incidental Medical Services (IMS) policy was discussed with the licensee. 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 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, www.ada.gov/childqanda.htm. This report, as well as the AAP Guide to Safe Sleep Practices brochure, were reviewed and discussed with the licensee. All licensing reports are public information and must be made available upon request for at least three years.

Notice of Site Visit shall be posted for 30 days from today's visit.

There were no Title 22 deficiencies cited during today's inspection.
SUPERVISOR'S NAME: Erin VirruetaTELEPHONE: (530) 895-4325
LICENSING EVALUATOR NAME: Mikah MartinezTELEPHONE: (530) 895-4014
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2020
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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