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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 243805494
Report Date: 07/07/2021
Date Signed: 07/07/2021 11:42:15 AM

Document Has Been Signed on 07/07/2021 11:42 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
CCLD Regional Office, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME:JEADELINE'SFACILITY NUMBER:
243805494
ADMINISTRATOR:PEREZ, MARIAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 720-9472
CITY:MERCEDSTATE: CAZIP CODE:
95340
CAPACITY: 14TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
07/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Perez - LicenseeTIME COMPLETED:
12:00 PM
NARRATIVE
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On 7/7/21 Licensing Program Analysts (LPAs), Joseph Pacheco and Roman Iglesias conducted an unannounced Annual Required Inspection and was met by Licensee, Maria Perez. Days and hours of operation are Monday through Saturday 3:00am – 5:30pm.
LPAs toured the home inside and outside and a census was taken. Current facility sketch reviewed and Licensee confirmed that the daycare room, kitchen, bathroom, living room and backyard are used for providing care and are accessible to children. All other rooms are off-limits and made inaccessible by use of locks. There is no swimming pool or other bodies of water on the premises. There are no firearms or ammunition on the premises. All poisons are kept in a locked storage area. No poisons were observed during the inspection. Detergents, cleaning compounds, medication and other hazardous items are made inaccessible.
The fireplace located in the living room and is made inaccessible by a glass door and will not be in use during daycare hours. There is a working fire extinguisher, smoke detector, carbon monoxide detector and adequate heating and ventilation for safety and comfort. There are no stairs in this home. Safe toys and play equipment are observed. The home has working telephone service and LPAs confirmed the phone number is (209) 720-9472.
There is currently one infant in care. LPAs discussed Safe Sleep Regulations with licensee. There is one crib or play yard for each infant in care, cribs and play yards are kept free from all loose articles and objects while infants are sleeping, and there are no objects hanging above or attached to the crib or play yard. Infants are not swaddled while in care. Provider physically checks on sleeping infants every fifteen minutes and documents any signs of distress which includes but is not limited to flushed skin color, increase in body temperature, restlessness and labored breathing. Infants can be visually observed through an open door if sleeping in a separate room. Individual Infant Sleeping Plan is completed and in file for each infant up to 12 months of age. Infants up to 12 months of age are placed on their backs for sleeping.
Licensee ensures that children in care are supervised at all times and is aware children shall not be left in parked vehicles. Car seats are used for transportation purposes only and are not used for sleeping children.
CONTINUED ON 809-C
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
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, 1310 E. SHAW AVE,
FRESNO, CA 93710
FACILITY NAME: JEADELINE'S
FACILITY NUMBER: 243805494
VISIT DATE: 07/07/2021
NARRATIVE
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The outdoor play area in the backyard is fenced and LPAs observed potential hazards to children in care. Capacity as specified on the license is being maintained.
LPA reviewed a sample of children’s files and observed files were complete with emergency information as required. Licensee’s Mandated Reporter Training was completed on 5/17/21. Licensee’s pediatric CPR/First Aid expires on 6/10/22. A review of records indicates that all employees and/or volunteers have immunization records on file for influenza, pertussis and measles.
All adults who reside or work in the home have a criminal record clearance or exemption. There are no excluded individuals present at this home.
Incidental Medical Services (IMS) are not currently being provided. Licensee is aware that an IMS plan is required to be submitted to the licensing office if they provide any of these services. Information regarding Americans with Disability Act (ADA) can be obtained by contacting US Department of Justice toll free ADA Information line at (800) 514-0301(voice), (800) 514-0383 (TDD) and website link https://www.ada.gov/childqanda.htm.

LPA and Licensee discussed the Community Care Licensing website www.ccld.ca.gov which will provide access to Provider Information Notices (PINs), Quarterly Updates, COVID-19 Information and Resources, Mandated Reporter Training, Safe Sleep in Child Care, Lead Poisoning Facts, Forms and Regulations.
Per Title 22, Division 12, Chapter 3, of the California Code of Regulations, the following deficiency is being cited: (see next page, 809 D) Licensee was provided a copy of appeal rights.
This report shall be made available to the public upon request. LIC 9213 Notice of Site Visit is provided and required to be posted for 30 days.
SUPERVISORS NAME: Diana deLeon
LICENSING EVALUATOR NAME: Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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Document Has Been Signed on 07/07/2021 11:42 AM - It Cannot Be Edited


Created By: Joseph Pacheco On 07/07/2021 at 11:14 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
, 1310 E. SHAW AVE,
FRESNO, CA 93710

FACILITY NAME: JEADELINE'S
FACILITY NUMBER: 243805494

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/21/2021
Section Cited
CCR
102417(g)

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Operation of a Family Child Care Home. The home shall be free from defects or conditions which might endanger a child. This requirement was not met as evidenced by LPAs observation of the backyard play area which contained cobwebs and spiders on the play equipment, broken furniture, rotting fruit on
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Licensee has agreed to remove the hazardous items by 7/21/21. A return inspection will be required.
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the ground, dog feces and an unlocked storage area which contained hazardous items. This poses a potential risk to health, safety, or personal rights of children in care.
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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:Diana deLeon
LICENSING EVALUATOR NAME:Joseph Pacheco
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021


LIC809 (FAS) - (06/04)
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