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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 293624237
Report Date: 03/21/2022
Date Signed: 03/21/2022 12:07:42 PM

Document Has Been Signed on 03/21/2022 12:07 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, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME:CARMONA, JESSICAFACILITY NUMBER:
293624237
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 9CENSUS: 0DATE:
03/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Carmona - LicenseeTIME COMPLETED:
12:30 PM
NARRATIVE
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On Monday, March 21st, 2022, at 10:02am, Licensing Program Analyst (LPA) Blake Morillas met with the Licensee, Jessica Carmona, for a Change of Location - Prelicensing inspection. This is a 2 story, 4 bedroom, 2 bathroom home. The Licensee owns the home and at this time the Licensee does not carry liability insurance. LPA explained about obtaining $300,000 liability insurance. Licensee understands that until a policy is obtained, they must use the affidavit.

Licensee 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.


At 10:04am, LPA initiated a health and safety inspection of all areas of the home as well as the outdoor areas. The Off-limit areas will be: Living Room, Front Bedroom, All Upstairs, Garage, Cellar, All Outbuildings. Licensee understands that children may never enter these off-limit areas.

Licensee has certificates of completion for Preventative Health and Safety training including CPR/First Aid (expires: 2/2024) and Mandated Reporter Training (expires: 2/2024.

LPA discussed current Covid-19 guidelines.

LPA reviewed the fire drill requirements. Fire extinguisher, carbon monoxide and smoke detectors meet regulation. Hazardous cleaning compounds and medications are stored inaccessible and out of reach of children. Licensee stated there are no weapons in the home.


Continued on LIC 809-C Page 1 of 3
SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Blake Morillas
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: CARMONA, JESSICA
FACILITY NUMBER: 293624237
VISIT DATE: 03/21/2022
NARRATIVE
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Continuation of LIC 809

There are stairs in the home as well a wood burning stove, both located in the off-limits area of the home. The off-limits area will be barricaded to prevent access by the children in care.

The outdoor area used by children is fenced and age appropriate toys were observed. Licensee understands that 100% supervision is required in any unfenced areas. There are no bodies of water on the premises.

LPA reviewed with licensee, 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. Entrance Checklist was provided to the licensee.

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.


This facility plans to provide Incidental Medical Services – IMS. For IMS information , see PIN 22-02-CCP. 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


Continued on LIC 809-C

Page 2 of 3

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Blake Morillas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.250
SACRAMENTO, CA 95833
FACILITY NAME: CARMONA, JESSICA
FACILITY NUMBER: 293624237
VISIT DATE: 03/21/2022
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Continuation of LIC 809-C

Effective today (3-21-2022) the facility is licensed to serve a MAX. CAP: 6 - NO MORE THAN 3 INFANTS OR 4 INFANTS ONLY. CAP 8 - NO MORE THAN 2 INFANTS, 1 CHILD IN KINDERGARTEN OR ELEMENTARY SCHOOL AND 1 CHILD AT LEAST AGE 6.

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.

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 notice of site visit was given and must remain posted on, or immediately adjacent to, the interior side of the main door for 30 days.

Exit interview conducted and report was reviewed with the licensee, Jessica Carmona.

Page 3 of 3

SUPERVISORS NAME: Keven Peters
LICENSING EVALUATOR NAME: Blake Morillas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3