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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495008
Report Date: 03/18/2022
Date Signed: 03/18/2022 02:04:24 PM

Document Has Been Signed on 03/18/2022 02:04 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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:JACOBS FAMILY CHILD CAREFACILITY NUMBER:
197495008
ADMINISTRATOR:RENEE JACOBSFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(818) 414-9988
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91606
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
03/18/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Renee Jacobs- ApplicantTIME COMPLETED:
02:15 PM
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On 3/18/2022 at 9:08am, Licensing Program Analyst (LPA) Suzette Ornelas and Licensing Program Manager (LPM) Claudia Escobedo conducted an announced Pre-Licensing Inspection at 6224 Klump Ave, North Hollywood, CA 91606. The purpose of the meeting was to ensure that health, safety and personal rights as required by Title 22 Regulations governing California Family Child Care homes will be met by the Applicant. This is an application for a Large Family Child Care Home for 14 children-ages 0 to 6 years of age. The home has an approved fire clearance dated 2/2/2022. The family child care home will operate Monday thru Friday 6:30 a.m. to 5:00 p.m. LPA met with Applicant, Renee Jacobs, who guided LPA on a tour of the inside and outside of the home. LPA observed 2 adults in the home and 0 children in care.

Per facility sketch and tour of the home, the following was observed and discussed with the Applicant during the inspection:


Home is a 1 story dwelling with 2 bedrooms, 2 bathrooms, 1 kitchen, 2 living rooms, 1 walk-in closet located in master bedroom, 1 laundry room and 1 dining room. Entering the home will lead to the 1st on-limits living room. To the left of the 1st living room is the on-limits dining room that leads to the off-limits kitchen. There is a hallway to the right of the 1st living room that leads to 1 on-limits bedroom, 1 on-limits bathroom, and 1 off-limits master bedroom which leads to 1 off-limits master bathroom and 1 off-limits walk in closet. Straight ahead of the 1st living room will lead to the 2nd on-limits living room that leads to the off-limits laundry room. On-limits outdoor area will be the backyard of the home. Per applicant, the outdoors left side gate leading to the driveway, will be locked during operating hours. The right side of the outdoor play area will have a safety gate to make the gate, which leads to the street, inaccessible to children in care. The home is equipped with a Ring camera doorbell. LPAs observed the following:

continued on LIC 809-C
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 03/18/2022
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· The 1st living room area is on- limits and will be used for child care activities. A posting board is visible with required documentation on display, which includes LIC 999A . Closets and drawers have been made inaccessible to children using safety latches. Electrical outlets have safety covers installed. Fireplace has been made inaccessible by a screen to prevent access by children. Room is equipped with one working carbon monoxide/smoke detector, as tested by the Applicant.
· The 2nd living room is on-limits and will be used for child care activities. Closets and drawers have been made inaccessible to children using safety latches. Electrical outlets have safety covers installed. Room is equipped with one working carbon monoxide/smoke detector, as tested by the Applicant.
· Dining Room is on-limits with one table and chairs and will be used when children eat. A wine cart has been made inaccessible to children in care by a baby gate.
· The kitchen is off-limits and is made inaccessible from the dining room area by a baby gate and a locked door that is accessible from the laundry room. Kitchen cabinet and drawers containing hazardous materials and sharp objects, including knives, are made inaccessible by safety latches.
· One laundry room is on- limits only when children exit to the backyard play area, there is one sink, two cabinets, washer and dryer.
· One bathroom is on-limits to children in care with a working toilet and sink as well as a tub and shower.
· One bedroom is on-limits to children in care with one crib and one rocking chair as well as the applicants work area. Electrical outlets have safety covers installed.
· One master bedroom leading to a master bathroom and a walk in closet is off-limits and made inaccessible to children in care by locking the door with a key.
· Front yard which is on-limits when children enter the home. The front yard will not be used as a play area.
· Backyard is on-limits play area and accessed through the laundry room. An air conditioning unit will be made inaccessible to children in care. 2 Storage sheds are made inaccessible to children in care by being locked with a key. Jacuzzi is made inaccessible to children in care by a locked lid.
· Garage is off-limits and is accessed through driveway. The garage is inaccessible to children in care by a locked gate.

continued on LIC 809-C
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
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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, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 03/18/2022
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The following was also observed by LPAs during the inspection
1. All adults living in the home have submitted fingerprints and child abuse index check forms to Department of Justice.
2. Home is neat and clean.
3. Fireplace is screened and inaccessible to children.

4. Home is equipped with a fully charged fire extinguisher which is at least a 2A:10BC.

5. Home is equipped with at least 2 working smoke alarm and a carbon monoxide detectors.


6. Home has a working telephone.
7. According to the Applicant, there are 2 shotguns that are stored in a storage shed located in the outdoor play area of the home. The firearms are stored in a locked box. Applicant states that there is no ammunition in the home.
8. Outdoor play area is not free from defects or dangerous conditions.
9. Outdoor play area is fenced in and the plan for supervision is: Applicant plans on visually supervising all children at all times; however, when there are more than 5 children in care, there will be an assistant. Baby gates will ensure all children are within the same area.
10. Bodies of water were observed during the inspection, Home does have a hot tub, covered and locked. On 3/18/2022 at approx. 1:40pm, a declaration was completed and signed by the applicant stating that the jacuzzi will be covered and locked at all times while children are in care.
11. Toys and play items are safe, clean, and appropriate for the ages of the children.
12. Applicant agrees that baby-walkers, bouncers, jumpers, and similar items will not be used for children in care and are kept inaccessible.
13. The home is equipped with a first-aid kit with, cleansing pads healing ointment, bandages, gauze, and a digital thermometer.
14. Hazardous materials are not inaccessible and not kept out of the reach of children.
15. All poisons, detergents, cleaning compounds, medications, etc. should not be accessible to children or are locked.

continued on LIC 809-C

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 03/18/2022
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The following was thoroughly discussed with the Applicant
· Applicant was made aware of The Child Care Advocate Program (CCAP) that is administered from within the Community Care Licensing Division. CCAP participates in many community activities and special projects in order to disseminate information on the State’s licensing role, provide information to the public and parents on child care licensing, and provide many other helpful resources to the licensees and the public. CCAP’s direct contact information is as followed: Phone number: (916) 654-1541.
Email Address: childcareadvocatesprogram@dss.ca.gov
· Commencing September 1, 2016, SB 792, prohibits a person from being employed or volunteering at a child care facility or family day care if he or she has not been immunized against influenza, pertussis and measles. LPA discussed the influenza waiver during the inspection.
· Beginning on January 1, 2018, AB 1207, requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Website: www.mandatedreporterca.com. Licensee was reminded of their responsibility to report suspected child abuse.

· Upon receipt by the licensee, licensees are to provide to parents/guardians the following: Copies of any licensing reports that document a Type A citation- this includes facility visits and substantiated complaint investigations; copy of licensing documents pertaining to a conference conducted by a local licensing agency management representative and the licensee of this family child care home in which issues of noncompliance are discussed or copies of a summary of an accusation indicating the Department's intent to revoke the facility's license. Copies of any of the above licensing documents the licensee has received in the prior 12 months shall be provided to parents/guardians of newly enrolled child at the facility. (AB) 633


· Applicant was advised that regulation prohibits the smoking of tobacco in a private residence licensed as a family child care home during the hours of operation.

· The fire extinguisher type 2A-10BC must be services annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries should be replaced.


continued on LIC 809-C
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 03/18/2022
NARRATIVE
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· A current roster of children enrolled must be maintained and available. 1596.841

· Applicant was reminded to report any unusual incidents or injuries to the Child Care Regional Office by telephone within 24 hours and in writing within 7 days.

· Mandatory Forms for the children’s files and provider’s files were discussed. Licensee was referred to LIC 311D: Records To Be Maintained At The Facility - Family Child Care Home.

· Applicant was reminded that all infants must be placed on their backs when sleeping to prevent S.I.D.S. (Sudden Infant Death Syndrome) and that the Provider is required to wash hands after every diaper change and to never shake a baby to prevent the Shaken Baby Syndrome. Safe to Sleep Campaign: https://safetosleep.nichd.nih.gov/materials19-02 CCP Safe Sleep Awareness Campaign

· Applicant was reminded that only children eating may be in highchairs and that car seats are utilized only for transportation.



· Applicant was made aware that state law prohibits baby walkers, bouncy seats, exersaucers and any other items that fall into that category. 1596.846(b)(c)

· Applicant was reminded that it is the licensee’s, as well as anyone who assists in providing care, responsibility to know the regulations. Licensee was advised on how to access quarterly reports, forms, and regulations for Child Care online at www.ccld.ca.gov. Licensee was also encouraged to read the Child Care quarterly updates as they come out to stay informed of any changes or updates to statutes and regulations.


· In the absence of the licensee a qualified adult must be present supervising the children; a qualified adult is an individual who has a valid and current adult/infant CPR& Pediatric First Aid certification and a valid criminal record clearance associated to the facility license.

continued on LIC 809-C

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 5 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 03/18/2022
NARRATIVE
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· Due to the COVID-19 pandemic and local and state ordinances, licensee was directed to the CCLD.CA.GOV website for important updates and PINS. Licensee was directed to PIN 22-10-CCP.
Plan of corrections have been discussed with Applicant, including:

· Windows blind cords located in all on-limit are need to made inaccessible to children in care.

· Candles in 1st living room need to be made inaccessible to children in care. (On 3/18/2022 at approx. 1:38pm, candles were made inaccessible to children by being removed.)

· Bedroom is on limits and work area/other items against that wall will be made inaccessible to children in daycare.

· Heater in hall/living room needs to made inaccessible to children.

· Laundry room is on-limits and 2 drawers will be made inaccessible to children in care by installing locks. (On 3/18/2022 at approx. 12:35pm, cabinets were made inaccessible to children with a safety latch.)

· Air conditioning unit in the backyard will be made inaccessible to children in care.


· Small metal table/chairs in the backyard will be made inaccessible to children in care.
· Bricks/small space behind storage shed in the backyard will be made inaccessible to children in care.
· Narrow right side of the home will be made inaccessible to children by installing a baby gate.
· Broken jacuzzi parts will be made inaccessible to children in care by being repaired or covered.
· Broken hose case will be made inaccessible to children in care by being repaired or covered.
· Knife cabinet will be made inaccessible in the off-limits kitchen, utensil latch drawer will be replaced. (On 3/18/2022 at approx. 12:35pm, cabinets were made inaccessible to children with a safety latch.)
· All poisons, detergents, cleaning compounds, medications, etc. should not be accessible to children or are locked. (On 03/18/2022 at 12:15 p.m. LPA observed that all poisons, detergents
· Hazardous materials are not inaccessible and kept out of the reach of children, including dog feces.
· LPA was not able to observe if fire arm has a trigger lock. (On 3/18/2022 at approx. 12:33pm, 2 firearms were observed to have a trigger lock.)
· Proof of 1 year experience/duties need from applicant.
continued on LIC 809-C
SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 6 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 03/18/2022
NARRATIVE
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· Applicant 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, 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 up to $500.00 maximum per day/per person will be assessed if this regulation is violated.

· LPA discussed the safe sleep regulations with applicant 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 applicant, 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 22-02-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 Centers and the ADA, available at: http://www.ada.gov/childqanda.htm



Exit interview conducted and report was reviewed with the applicant, Renee Jacobs.

LPA reviewed with applicant, Renee Jacobs the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted



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 platform.

continued on LIC 809-C

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
Page: 7 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 03/18/2022
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To receive important licensed-related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-care-licensing/subscribe and select the Child Care option to receive email communication.

A copy of this report was provided to the Applicant. Final license determination will be made upon review by the Licensing Program Manager and correction of the above issues. Applicant to correct items by . 03/01/2022.

SUPERVISORS NAME: Claudia Escobedo
LICENSING EVALUATOR NAME: Suzette Ornelas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2022
LIC809 (FAS) - (06/04)
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