197400162-9-21-2023-58-CC-SSAZ-CVVQ9Y-20230921115908

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197400162
Report Date: 09/21/2023
Date Signed: 09/21/2023 11:59:18 AM

Document Has Been Signed on 09/21/2023 11:59 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME:	JACKSON FAMILY DAY CARE		FACILITY NUMBER:	197400162
ADMINISTRATOR:	BRENDA JEAN JACKSON		FACILITY TYPE:	810
ADDRESS:			TELEPHONE:	(323) 735-6991
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90016
CAPACITY: 12	TOTAL ENROLLED CHILDREN: 12	CENSUS: 0	DATE:	09/21/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Brenda Jackson, Licensee		TIME COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Susann Sanchez and Angelica Wallin conducted unannounced annual continuation visit from 08/31/23. LPAs met with Brenda Jackson. With permission from the Licensee, LPAs gave themselves a tour of the facility. There were no children present. Facility capacity is in compliance for a Large Family Child Care Home. Per Licensee, hours of operation will be Monday through Sunday, and is open 24/7 but states that she does not to exceed 24 hour care at one time. Licensee states that she will care for children 2 years to 13 years old. The home is a single story 3 bedroom, 3 bathroom dwelling with a detached back house. Licensee stated presently using the living room for activities, bathroom and front yard. All other areas are "off limit." A Licensee has a laundry room adjacent to the back house that remains closed and inaccessible to the children. Licensee states there are no firearms or weapons in the home and no bodies of water. All individuals present in the home have obtained a criminal record clearance or exemption prior to working, residing or volunteering in a licensed home. All areas identified on the facility sketch that children use, were inspected for safety, comfort, cleanliness, telephone service, ventilation and heating (central). The following was observed and reviewed during this inspection. LPAs reviewed required posted documentation for Facility License, Publication (PUB) 394- Notification of Parent Rights and Licensing Form (LIC) 9148- Earthquake Preparedness form. Facility records were reviewed for LIC 9040- Facility Roster, LIC 610- Facility Disaster Plan and Disaster drill log, last drill conducted on 09/11/23. Smoke and carbon monoxide detectors were tested and are operable on 08/31/23.The home is observed to be clean and orderly. There are toys and other age appropriate material available for children. LPAs observed that detergents, cleaning compounds under the kitchen sink. LPAs advised Licensee to remove items when children are present.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JACKSON FAMILY DAY CARE	FACILITY NUMBER: 197400162
	VISIT DATE: 09/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee states that there are no poisons stored in the home and understands that all poisons must be lock, not only inaccessible to children. Isolation area for sick children waiting to be picked up is in living room, away from the other children.

Licensee stated that she does not plan to watch infants in the future. LPAs informed licensee of the new Safe sleep regulations, including LIC 9227 Infant Sleep Plan for infants under 12 months, 15-minute sleep check documentation for infants 0-24 months, and provided PIN 20-24-CCP. LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage ahttps://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.
Children are using the front yard for outdoor play. Per Licensee stated that children are fully supervised when child is outside. LPA observed that the outdoor yard has toys and other materials for children to play with. LPA did not observe any objects that could be hazardous to children in care.

Children’s records were reviewed for (LIC) 282- Affidavit Regarding Liability Insurance, Immunizations Records, LIC 700- Identification and Emergency Information, LIC 627- Consent for Medical Treatment, LIC 995A Notification of Parents’ Rights.

Staff records were reviewed for approved: LIC 508- Criminal Record Statement, Proof of immunization against measles, pertussis and influenza or influenza declination, TB clearance or risk assessment, LIC 9108- Statement Acknowledging Requirement to Report Child Abuse, and Mandated Reporter (expire 09/02/25).

At 11:00am during staff file review, Licensee stated that she took a Pediatric First Aid and CPR training on 09/19/23 with the American Red Cross. However, LPAs did not observed any certification. Licensee called the instructor Derek Hill, who stated that the American Red Cross has not emailed certificate yet. Type B was cited.

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JACKSON FAMILY DAY CARE	FACILITY NUMBER: 197400162
	VISIT DATE: 09/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Licensee was reminded that all adults 18 and over, including employees and volunteers, expect 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 up assessed if this regulation is violated.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. 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 Center and the ADA, available at: http://www.ada.gov/childqanda.htm

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

To improve the quality and value of the new inspection process, a survey will 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 them by email 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/process.

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

Based on the LPA’s observations and records review, the following deficiencies listed on the attached LIC 809 (deficiency page) are being cited in accordance with California Code of Regulations Title 22. Division 12, Chapter 1, Section H&C.

A notice of site visit was given and must remain posted for 30 days. Appeal Rights were given and explained. Exit interview conducted and report was reviewed with the Licensee, B. Jackson

SUPERVISORS NAME: Valarie Cook
LICENSING EVALUATOR NAME: Susann Sanchez
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 09/21/2023 11:59 AM - It Cannot Be Edited

Created By: Susann Sanchez On 09/21/2023 at 11:36 AM

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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JACKSON FAMILY DAY CARE	FACILITY NUMBER: 197400162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

102416(c)

Personnel Requirements

(c) The licensee and other personnel as specified shall complete training on preventive health practices, including pediatric cardiopulmonary resuscitation and pediatric first aid, pursuant to Health and Safety Code Section 1596.866. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above. Per Licensee took CPR & 1st Aid on 09/19/23 but the agency has not send her the certification yet. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/05/2023
	Plan of Correction
1 2 3 4	Licensee will provide proof of current in person CPR and First Aid training via email by POC due date of 10/05/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Valarie Cook

LICENSING EVALUATOR NAME:

Susann Sanchez

LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4