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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409565
Report Date: 08/19/2024
Date Signed: 08/19/2024 04:06:30 PM

Document Has Been Signed on 08/19/2024 04:06 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:LEE, JASMINEFACILITY NUMBER:
073409565
ADMINISTRATOR/
DIRECTOR:		JASMINE LEEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 414-3163
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jasmine LeeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On 08/19/2024 at 1:30PM, Licensing Program Analysts (LPA's) Kareeca Sykes and Christina Watts conducted an announced CHANGE OF LOCATION Pre-licensing Inspection and met with licensee, Jasmine Lee. During the prelicensing inspection, there were no children in care. Licensee was present alone in the home during inspection. Living in the home are licenee and licensee's school aged children. Days and hours of operation will be Monday – Friday from 5 AM - 7:00 PM.

Licensee completed 8 hour Preventative Health & Safety training, Nutrition and Lead Poisoning training, 8 hour Pediatric CPR & First Aid Certificate that expires 08/2026, and has documentation for Measles, Pertussis, Influenza opt out statement for the current flu season. Licensee has Criminal Record and Child Abuse Index Clearance and documentation for Tuberculosis (TB) clearance. Licensee rents the home and has provided landlord consent: Because the Licensee rents the home, proof of landlord notification is required. The LPA's observed the Property Owner/Landlord Notification form (LIC 9151) that the applicant confirms was provided to the property owner/landlord. The licensee obtained a signed Property Owner/Landlord Consent form (LIC 9149). Licensee stated they will not carry Liability Insurance for the facility.Licensee has a working telephone in the home. Licensee has completed Mandated Reporter training which certificate expires 08/2026. Fire clearance was granted clearance 08/05/2024

This facility is a two story home composed of 5 bedrooms, 3 bathrooms, Living Room, Kitchen, Dining Room and backyard.
Areas on limits: Loft, Upstairs bathroom, licensee will use front entry way and stairs as a way to enter and exit the loft where children will be in care..

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SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Kareeca Sykes
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: LEE, JASMINE
FACILITY NUMBER: 073409565
VISIT DATE: 08/19/2024
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Off-Limit Areas: Entire downstairs, all bedrooms, master bathroom, attached garage, and backyard.
(Licensee elected for her entire downstairs to be off-limits, per inspector Chris Giddis the emergency exit is through the backyard to the right side of the home. In case of emergency the are stated above can be used. Licensee cannot use that area outside any case of emergency)

Isolation Area: Upstairs loft

LPA's toured the indoor space of the home. The home is sanitary and orderly, with heating and ventilation for safety and comfort. There are stairs in the home that are made inaccessible to children. LPA's observed fully charged 2A10BC fire extinguisher, working smoke, carbon monoxide detector. Medicines, cleaning products, sharp objects are stored inaccessible to children. Door access to off limit areas are made inaccessible to children. LPA's reminded licensee that smoking, baby walkers, bouncers, jumpers and similar items are not allowed in family child care home. Licensee states there are no firearms and ammunition stored in the home. Licensee stated there are no pets in the home.


Outdoor Space: LPA's toured the outdoor area which will be off limits and licensee stated that children will go to the park for outdoor play.

Licensee understands that children's personal rights should not be violate. Isolation of sick children, supervision of children, capacity options, transportation of children, requirements for reporting suspected child abuse, unusual incidents/injuries and requirements for assistant/substitute were also discussed. Fire and earthquake drills must be conducted twice every six months and documented.

LPA's discussed and reminded licensee day care needs to be operated within the limitations and capacity of a Large Family Child Care Home with regards to ratios and that Licensee has to be present in the day care for 80% of the operation hours. Facility does not provide transportation for children,but licensee understands that children cannot be left alone, unattended in parked vehicles.

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SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Kareeca Sykes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: LEE, JASMINE
FACILITY NUMBER: 073409565
VISIT DATE: 08/19/2024
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This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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.

LPA's discussed the safe sleep regulations with licensee, and discussed the Child Care Licensing Safe Sleep web page at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/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.

Licensee was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

On this date, 06/11/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Licensee was informed of the MyChildCarePlan.org site, 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.

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SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Kareeca Sykes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: LEE, JASMINE
FACILITY NUMBER: 073409565
VISIT DATE: 08/19/2024
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Website links for provider resources:

Licensing forms, Title 22 regulations, can be obtained through the internet at www.cdss.ca.gov


Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms. To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

As of 08/19/2024, this facilities Large Family apllication has been approved.

Exit interview was conducted with Licensee Jasmine Lee and signed the report acknowledging receipts of documents.
SUPERVISORS NAME: Sherelle Johnson
LICENSING EVALUATOR NAME: Kareeca Sykes
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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