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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197495008
Report Date: 04/10/2025
Date Signed: 05/14/2025 03:59:41 PM

Document Has Been Signed on 05/14/2025 03:59 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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME:JACOBS FAMILY CHILD CAREFACILITY NUMBER:
197495008
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 5CENSUS: 2DATE:
04/10/2025
TYPE OF VISIT:Required - 3 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Renee JacobsTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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On 4/10/2025, Licensing Program Analyst (LPA) Amelia Morales conducted an unannounced- Required 3 Year inspection to the above facility. The purpose of the inspection was to ensure that health, safety, and personal rights as required by Title 22 Regulations governing California Family Child Care Homes are being met by the Licensee. LPA Morales was greeted by Licensee Renee Jacob's, the facility has been licensed for Small (8) Family Child Care home license since 5/06/2022. The Licensee is applying for an increase of capacity; Large Family Child Care Home license for a maximum capacity of 14. The Fire clearance was granted on 3/5/2025 by LA City Fire Prevention Bureau. An entrance checklist was provided. A census was taken there were 2 children during the time of the visit. The children’s roster was reviewed and is current. Per licensee, the facilities hours of operation are Monday through Friday 6:30 AM to 6:00PM.

This is a single dwelling home which consist of; 3 bedrooms, 2 bathrooms, kitchen, living room, laundry room, day-care room, garage, front yard, deck, shed, and backyard(fenced).

Per Licensee, areas off limits to children and parents include: bedroom #1, bedroom #2, bathroom #2, kitchen, garage, deck and shed. The kitchen has a baby gate making it inaccessible to the children in care. Per Licensee, food is provided such as snacks, lunch and dinner.

Per Licensee, areas that are accessible to children include; bathroom #1, bedroom#3 (playroom). LPA observed mats, as well as 3 play yards/cribs visible in the playroom. Napping equipment does not block entrances or exits. Infant mattresses were observed to be firm with tightly fitted sheets. LPA did not observe loose object, bumpers, objects hanging, or objects attached to the cribs/play yards. Living room, which has a fireplace. The fireplace is screened and inaccessible to children in care. The required postings are located in the living room.

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NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Amelia Morales
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/10/2025
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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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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 04/10/2025
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The laundry room, which is used as an exit, to get to the backyard. Children utilize the backyard (day care area to play).  LPA observed that the outdoor play area is fenced. Per applicant, when children are having outside time, they will ensure 100% supervision and never leave children unattended. There is a jacuzzi in the backyard next to children’s play area. LPA observed 4 locks to the jacuzzi, a hard cover. LPA Morales asked Licensee to stand on the hard cover to see if it can withstand an adults weight. Licensee compiled and stood above the jacuzzi hardcover, the hardcover withstood the weight.

Licensee has placed a pad lock to the fence to prevent accessibility to that area where the jacuzzi is at. Licensee advised LPA that no children will have access to the jacuzzi as it is off limits at all times. Licensee asked LPA if the day-care room can be used for eating and sleeping. LPA Morales informed Licensee that the day-care room can only be used for activities, and children may not eat or sleep there. However, LPA Morales informed Licensee that if they are able to provide a certificate of occupancy they may use the day-care room for napping and eating.

LPA observed the following: the home is clean and orderly. There were age-appropriate toys and play items. Licensee was informed that baby-walkers, bouncers, jumpers, and other prohibited items will not be used for children in care. All electrical outlets have safety covers. Detergents, cleaning compounds, medications, and other items which can pose a danger to children are inaccessible. The Licensee states that there are no poisons in the home. The Licensee does understand that poison must be locked with a key or combination lock. Per licensee, there is a pet( dog) and LPA did observe a small yorkie at the time of visit.  Per Licensee, isolation area for sick children is in the living room couch. The main entry is the side gate, which is used to enter the facility.

The Smoke/carbon monoxide detectors were observed­ in the living room, bedroom#3 (playroom), day-care room, tested and found to be operable. The required (2A10BC) fire extinguisher was observed in the laundry room and day-care room and were purchased on 12/15/2024.

The Licensee has current Pediatric First Aid and CPR. Proof of immunization against influenza, pertussis, and measles was readily available during today’s inspection. The Licensee has also taken the Mandated Reporter Training.

— Pediatric First Aid and CPR Card valid until: 10/28/2025
— Mandated Reporter AB1207: 10/23/2025

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NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Amelia Morales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 04/10/2025
NARRATIVE
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The Licensee has current Pediatric First Aid and CPR. Proof of immunization against influenza, pertussis, and measles was readily available during today’s inspection. The Licensee has also taken the Mandated Reporter Training.

— Pediatric First Aid and CPR Card valid until: 10/28/2025
— Mandated Reporter AB1207: 10/23/2025

To improve the quality and value of the new inspection process, a survey may 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 email inquiries 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.

Licensee was reminded that all adults 18 and over living or working in the home, 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.

LPA discussed the safe sleep regulations with licensee [or facility representative] 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 [or facility representative] 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.

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NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Amelia Morales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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
EL SEGUNDO CC NORTH, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245
FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008
VISIT DATE: 04/10/2025
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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: https://www.ada.gov/resources/child-care-centers/.

Licensee [or facility representative] was informed of the MyChildCarePlan.org website; 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.

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

A notice of site visit was given and must remain posted for 30 days.

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














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NAME OF LICENSING PROGRAM MANAGER: Betty Bell
NAME OF LICENSING PROGRAM ANALYST: Amelia Morales
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2025 03:59 PM - It Cannot Be Edited


Created By: Amelia Morales On 04/10/2025 at 02:21 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
, 300 CONTINENTAL BLVD. STE 290A
EL SEGUNDO, CA 90245

FACILITY NAME: JACOBS FAMILY CHILD CARE
FACILITY NUMBER: 197495008

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102425(j)(2)
Infant Safe Sleep
The provider shall supervise infants while they are sleeping and adhere to the following requirements: The provider shall check and document the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 3childrens files did not have safe sleep log, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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Licensee will montor and doucment safe sleep log for infants in care and submit proof to LPA Morales via email by POC date.
Type B
Section Cited
CCR
102425(c)
Infant Safe Sleep
An Individual Infant Sleeping Plan [LIC 9227 (3/20)] shall be completed for each infant up to 12 months of age the provider has in care and included in the infant's file at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 3 files reviewed did not have the LIC 9227, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2025
Plan of Correction
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Licensee will monitor and submit the LIC 9227 to LPA Morales by POC 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.
Betty Bell
NAME OF LICENSING PROGRAM MANAGER:
Amelia Morales
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2025


LIC809 (FAS) - (06/04)
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