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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197419585
Report Date: 12/17/2021
Date Signed: 12/17/2021 02:29:11 PM

Document Has Been Signed on 12/17/2021 02:29 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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME:JONES FAMILY CHILD CAREFACILITY NUMBER:
197419585
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
12/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Kharla JonesTIME COMPLETED:
02:46 PM
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Licensing Program Analyst (LPAs) King-Lewis and Stepanyan conducted a required 1 year Inspection with licensee Kharla Jones who guided analyst on a tour of the license day-care. The day care take place in the following area of the home: family room/playroom, and hallway bathroom. Licensee states her rear yard is still off limits for daycare children. Licensee states she will provide care for 24 hours Monday thru Friday. LPAs were greeted by licensee's mother who stated she is visiting daughter. Currently living in the home is licensee and licensee's 2 minor sons.

Physical Plant:

There are no body of water on the premises. Licensee stated there are no firearms or other dangerous weapons. Storage areas for poisons, medication shall be inaccessible to children and locked in laundry room and upstairs off limits area. Detergents, cleaning compounds and other items which could pose a danger to children are inaccessible to children stored up high in locked laundry room. LPAs observed screen fireplace inaccessible to children. Fire extinguishers, smoke detectors, and carbon monoxide appear to be operable. LPAs observed the home to be clean and orderly, central air and heating available. LPAs observed the stairs

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585
VISIT DATE: 12/17/2021
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with no barricade. Licensee stated cell phone is always available and charged, during day-care hours. LPAs did not observe a crib or play pen for infants use. Licensee stated she had read the safe sleep regulation. Licensee stated she is not currently caring for any infants. Licensee aware when infants are present the crib or play pen shall have a firm mattress and shall be free from loose articles and objects.

LPA discussed safe sleep regulation. Licensee aware no infant shall be swaddle and car seat shall not be used for sleeping. Licensee is aware to supervise infants while they are sleeping by physically checking every 15 minutes and documenting the child status. Licensee is aware all infants shall have an individual infant Sleeping Plan (LIC 9227). Licensee should refer to regulation 102425(J) for documentation requirement. LPA reviewed requirement with licensee during this inspection visit.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-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.

Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585
VISIT DATE: 12/17/2021
NARRATIVE
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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 (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

Care and Supervision

Licensee is aware she must be present in the home and shall ensure that children in care are supervised at all times. Licensee states she provides transportation. LPA informed licensee to make sure the transportation vehicle is properly insured to transport day care children. Licensee is aware the capacity stated on the facility license shall be the maximum number of children being cared for at one time.

Facility Records Review

LPAs did not observed facility current roster of children, current fire and disaster drill, and current mandated reporter training certificate. Licensee is aware that all employees or volunteer at the day-care shall be immunized against pertussis and measles and maybe immunized against influenza.

Facility Administration

Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, must obtain a criminal record clearance or

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585
VISIT DATE: 12/17/2021
NARRATIVE
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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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

Licensee aware to immediately remove individual and prevent individual for returning to the home or having contact with children in care upon notice from the department to remove an individual and all individuals subject to a criminal record review shall obtain a criminal record clearance or exemption prior to working, residing or volunteering in the license home. Licensee is aware any authorized employee of the Department may enter and inspect any place providing personal care and services at any time with or without advance notice. Licensee is aware other personnel shall complete training on preventive health practices including CPR and first aid per regulation 102416 (c). Licensee CPR and first aid card expires 12-01-2023.

Licensee is aware of the requirement to report unusual incidents and/or injuries to the parent/guardian and Licensing within 24 hours of incident by telephone and in writing within 7 day of incident on the form LIC624B per the regulation.

During this inspection facility was observed not to be in compliance with Title 22. Please see LIC 809D for deficiencies.

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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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, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551
FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585
VISIT DATE: 12/17/2021
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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 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/inspection-process.

Exit interview conducted and report was reviewed with the licensee a copy of this report and a notice of site visit was given and must remain posted for 30 days

SUPERVISORS NAME: Mariela Ramon
LICENSING EVALUATOR NAME: Lady King
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021
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Page: 10 of 12
Document Has Been Signed on 12/17/2021 02:29 PM - It Cannot Be Edited


Created By: Lady King On 12/17/2021 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(3)
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: (3) Where children are less than five years old are in care, stairs shall be fenced or barricaded.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and licensee's statment the licensee did not comply with the section cited above due to licensee was not able to make stairs inaccessible during this inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
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Licensee shall provide safe baracade for the stairs
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, licensee was not able to provide proof of fire and emergency drill conducted within the last 6 months. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
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Licensee shall conduct and provide proof of emergency disaster drill by Plan of Correction due date.
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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/17/2021 02:29 PM - It Cannot Be Edited


Created By: Lady King On 12/17/2021 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1596.8662(b)(1)
Administration of Child Day Care Licensing
(1) On or before March 30, 2018, a person who, on January 1, 2018, is a licensed child day care provider, administrator, or employee of a licensed child day care facility shall complete the mandated reporter training provided pursuant to paragraphs (2) and (3) of subdivision (a), and shall complete renewal mandated reporter training every two years following the date on which he or she completed the initial mandated reporter training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and licensee's statment, licensee does not have current mandated reporter training certificate. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
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Licensee shall completed mandated reporter trainnig and provided copy of training certificate by Plan of Correction due date.
Type B
Section Cited
CCR
102417(g)(7)
Operation of A Family Child Care Home
(7) An emergency information card shall be maintained for each child and shall include the child's full name, telephone number and location of a parent or other responsible adult to be contacted in an emergency, the name and telephone number of the child's physician and the parent's authorization for the licensee or registrant to consent to emergency medical care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPAs did not observe a completed child file. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
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Licensee shall have completed file for current child in care and ensure a file is available for future child enrolled in the facility.
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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 12/17/2021 02:29 PM - It Cannot Be Edited


Created By: Lady King On 12/17/2021 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)
Admission Procedures and Parental and Authorized Representative's Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, LPAs did not observe a completed child file. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
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Licensee shall have completed file for current child in care and ensure a file is available for future child enrolled in the facility.
Type B
Section Cited
CCR
102421(a)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPAs did not observe a completed child file. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
1
2
3
4
Licensee shall have completed file for current child in care and ensure a file is available for future child enrolled in the facility.
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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 12/17/2021 02:29 PM - It Cannot Be Edited


Created By: Lady King On 12/17/2021 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(a)(1)
Child's Records
(a) The licensee shall maintain, in each child's record, the signed and dated notice form required in Section 102419(d). (1) The licensee shall keep the signed and dated notice form for at least three years following
termination of service to the child.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPAs did not observe a completed child file. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
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2
3
4
Licensee shall have completed file for current child in care and ensure a file is available for future child enrolled in the facility.
Type B
Section Cited
CCR
102421(b)
Child's Records
(b) The licensee shall maintain, in each child's record, a copy of the emergency information card as required
in Section 102417(g)(7).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPAs did not observe a completed child file. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
1
2
3
4
Licensee shall have completed file for current child in care and ensure a file is available for future child enrolled in the facility.
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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 12/17/2021 02:29 PM - It Cannot Be Edited


Created By: Lady King On 12/17/2021 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102421(c)
Child's Records
(c) In any case in which the licensee cares for an additional child pursuant to Section 102416.5(b) for a Small Family Child Care Home or Section 102416.5(d) for a Large Family Child Care Home, the licensee shall maintain, in the child’s record, a copy of documentation verifying the child’s enrollment and attendance at kindergarten, including transitional kindergarten, or elementary school as required in Section 102416.5(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPAs did not observe a completed child file. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
1
2
3
4
Licensee shall have completed file for current child in care and ensure a file is available for future child enrolled in the facility.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
1
2
3
4
Licensee will provide a current facility roster and update roster as new children are enrolled.
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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 12/17/2021 02:29 PM - It Cannot Be Edited


Created By: Lady King On 12/17/2021 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102419(d)(1)
Admission Procedures and Authorized Representatives Rights
(d) At the time of acceptance of each child into care, the licensee shall provide the child's parent or authorized representative with a copy of the notice Family Child Care Home Notification of Parent's Rights, LIC 995A (8/06), the Caregiver Background Check Process, LIC 995E (6/05), and the Family child Care Consumer Awareness Information, LIC 9212 (10/05). (1) The licensee shall request the child's parent or authorized representative to sign and date the bottom portion of the notice form LIC 995A (8/06), which acknowledges that the parent or
authorized representative has received and read the LIC 995A. The bottom portion of this form
must be kept in the child’s file as proof that the parent or authorized representative has been
notified of his or her rights and received a copy of the Caregiver background Check Process, LIC
995E (6/05), and the Family Child Care Consumer Awareness Information, LIC 9212 (10/05).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPAs did not observe a completed child file. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
1
2
3
4
Licensee shall have completed file for current child in care and ensure a file is available for future child enrolled in the facility.

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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 12/17/2021 02:29 PM - It Cannot Be Edited


Created By: Lady King On 12/17/2021 at 01:23 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
, 39115 TRADE CENTER DR STE. 201
PALMDALE, CA 93551

FACILITY NAME: JONES FAMILY CHILD CARE
FACILITY NUMBER: 197419585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(m)(3)
Operation of A Family Child Care Home
(3) A file of affidavits signed by each parent with a child enrolled in the home. The affidavit shall state that the parent has been informed that the family child care home does not carry liability insurance or a bond according to standards established by the state.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPAs did not observe a completed child file. The licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2021
Plan of Correction
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Licensee shall have completed file for current child in care and ensure a file is available for future child enrolled in the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Mariela Ramon
LICENSING EVALUATOR NAME:Lady King
LICENSING EVALUATOR SIGNATURE:
DATE: 12/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2021


LIC809 (FAS) - (06/04)
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