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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073409575
Report Date: 07/18/2025
Date Signed: 07/18/2025 11:34:43 AM

Document Has Been Signed on 07/18/2025 11:34 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
OAKLAND CC RO, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:JACKSON, KAUSHAFACILITY NUMBER:
073409575
ADMINISTRATOR/
DIRECTOR:		KAUSHA JACKSONFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(510) 275-9883
CITY:RICHMONDSTATE: CAZIP CODE:
94806
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 3DATE:
07/18/2025
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Kausha JacksonTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 07/18/2025 at 10:00 AM Licensing Program Analyst (LPA) Ashley Hollinger conducted an UNANNOUNCED, Required Annual inspection at Kausha Jackson's Family Childcare Home. LPA met with 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 - Friday, 06:45 AM to 5:45 PM. Present in the home at the time of inspection were Licensee and three (3) children in care consisting of two (2) toddlers and one (1) school-ager.

The home is a two story house that consists of five bedrooms, three bathrooms, dining room, living room, family room, a two car garage, and a fully fenced in large backyard.


ON-LIMIT areas: the dining room, living room (located next to the entrance), family room (located next to the kitchen), the downstairs bedroom (primary day care area), and the downstairs bathroom.

OFF-LIMIT areas: the entire upstairs, the garage, backyard. All off limit areas are made inaccessible by closed and/or locked doors and visual supervision. The Isolation area is in the living room next to the main entrance.

Medicines, cleaning products, and sharp objects are stored inaccessible to children in care during today's inspection. The home maintains a working telephone. Licensee was reminded that smoking is not allowed in a family childcare home. Licensee states that there are no pets in the home. Licensee stated there are no firearms or ammunition stored in the home.

See LIC809-C--------------------------------------------------------------------------------------------------------------

NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Ashley Hollinger
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: JACKSON, KAUSHA
FACILITY NUMBER: 073409575
VISIT DATE: 07/18/2025
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There is a 2A10BC fire extinguisher, working smoke and carbon monoxide detector located in the home. There is an electric fireplace in the living room but it is screened and does not get turned on while children are in care. Children files and facility files were reviewed and facility also contains a Children's Roster and Fire/Disaster Drill. Facility has central heating throughout the home. Licensee's Mandated Reporter training expired on 02/01/2025 but will be recertifying on 07/24/2025 and CPR/Pediatric First Aid certification expires 02/12/2026. LPA observed there are no pools, hot tubs or other bodies of water. The home is sanitized and orderly in compliance with Title 22 Regulations during today's inspection, with heating and ventilation for the safety and comfort of children in care.

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 which includes 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/.

See LIC809-C--------------------------------------------------------------------------------------------------------------

NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Ashley Hollinger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
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: JACKSON, KAUSHA
FACILITY NUMBER: 073409575
VISIT DATE: 07/18/2025
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Licensee has obtained a signed Property Owner/Landlord Consent form (LIC9149) signed by the landlord and provided a proof of control of the property.

On this date, 07/18/2025, 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.

No Deficiencies were observed during today's visit.

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

Exit interview conducted and report was reviewed with Licensee, Kausha Jackson.

NAME OF LICENSING PROGRAM MANAGER: Monica Mathur
NAME OF LICENSING PROGRAM ANALYST: Ashley Hollinger
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5