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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 013423590
Report Date: 07/13/2023
Date Signed: 07/13/2023 02:57:04 PM

Document Has Been Signed on 07/13/2023 02:57 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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:JACKSON, LAHOMAFACILITY NUMBER:
013423590
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 3DATE:
07/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Lahoma JacksonTIME COMPLETED:
03:15 PM
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On 07/13/2023 at 11:30 AM Licensing Program Analyst (LPA) Diana Campos conducted an unannounced Annual Required inspection at Lahoma Jackson Family Childcare Home. LPA met with the licensee and explained the purpose of today's inspection. LPA was granted the inspection authority to enter the Home. The family childcare home days and hours of operation are Monday to Saturday 06:00 AM to 06:00 PM. Present in the home at time of inspection were licensee, and 3 children in care consisting of 1 preschool and 2 school age.
Indoor Space: At 12:00 PM a health and safety tour of inside the home was done. LPA toured the premises with licensee. The home is a multi-level house consisting of 3 bedrooms, 2 bathrooms, living room, dining room, eat-in kitchen, and family room. There is heating and ventilation for the safety and comfort of children in care.
Outdoor Space: At 1:00 PM LPA toured the outdoor area (backyard) and observed it was fenced. LPA observed there are no pools, hot tubs or other bodies of water. LPA observed the rear portion of the backyard is blocked off to prevent access to children in care. LPA observed a small trampoline. Licensee was reminded that 100% visual supervision is required when day care children use the outdoor area as well as to always follow the manufacture guidelines when day care children use the trampoline. There does not appear to be any dangerous hazards in the backyard such as poisons or toxins during today's inspection. OFF-LIMIT areas are the entire upper level of the home, the living room, dining room, and the rear area of the backyard. LPA observed these areas are kept inaccessible by closed and/or locked doors; child proof gates and visual supervision. Stairs are blocked with child proof gates. IN-USE The eat-in kitchen, family room (on lower level), bathroom on lower level and backyard is used as the primary areas for day-care. Isolation area for sick children is the downstairs bedroom.
Medicines, cleaning products, and sharp objects are stored inaccessible to children in care during today's inspection. The fireplace is blocked to prevent access to children in care, heating vents are located near ceiling out of reach to children in care. The home maintains a working telephone. Licensee was reminded that smoking is not allowed in a family child care home. Licensee was reminded that baby walkers, bouncers, jumpers and similar items are not allowed in family childcare homes. Per license there are no pets in the home. Licensee stated there are no arms and ammunition stored in the home. There is a 3A40BC fire extinguisher, smoke and carbon monoxide detector in the home. Children files and Facility files were reviewed. Facility contained a Children's Roster, pediatric CPR and first aid expires 5/2025.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JACKSON, LAHOMA
FACILITY NUMBER: 013423590
VISIT DATE: 07/13/2023
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep as an additional resource. LPA also informed 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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02CCP. 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: https://www.ada.gov/resources/child-care-centers/.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

During the exit interview, the LICENSEE, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was given and must remain posted for 30 days. The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Exit interview conducted and report was reviewed with the licensee Lahoma Jackson.

SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Diana Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2023 02:57 PM - It Cannot Be Edited


Created By: Diana Campos On 07/13/2023 at 02:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612

FACILITY NAME: JACKSON, LAHOMA
FACILITY NUMBER: 013423590

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation and record review)], the licensee did not comply with the section cited above in that an emergency disaster plan was not made available during inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/11/2023
Plan of Correction
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Licensee will submit a copy of the emergency disaster plan by the POC to licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sherelle Johnson
LICENSING EVALUATOR NAME:Diana Campos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2023


LIC809 (FAS) - (06/04)
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