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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 304314493
Report Date: 03/13/2025
Date Signed: 03/13/2025 12:23:21 PM

Document Has Been Signed on 03/13/2025 12:23 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
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME:SERVELEON, JESSICAFACILITY NUMBER:
304314493
ADMINISTRATOR/
DIRECTOR:		FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
03/13/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:33 AM
MET WITH:Applicants, Jessica Serveleon and Stephanie Toga Dominguez TIME VISIT/
INSPECTION COMPLETED:
12:22 PM
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On 3/13/2025, Licensing Program Analyst (LPA) Nunez conducted an announced, in-person Pre-Licensing inspection for a new Small Family Child Care home. The LPA met with applicants Jessica Serveleon and Stephanie Toga Dominguez, who provided a tour of the home. A review of the Facility Personnel Report Summary indicates 5 adults live in the home. The adult residents received caregiver background check clearances or exemptions as required by the Department. Per the applicant, there is 1 minor living in the home.

The applicants stated that they are not registered with any Resource Foster Care agency and that she does not hold a Resource foster parent license. The applicant was reminded to notify the licensing office of any changes.

The applicant is requesting a Small Family Childcare Home license. Per the applicant, operation hours will be Monday through Friday, 6:00 AM- 6:00 PM. Care and supervision will be provided to children ages newborn to 12 years old. For the purposes of licensing, an infant is defined as any child 0 to 24 months of age.

All areas on the Facility Sketch LIC999 were inspected, including but not limited to, off-limits areas. The facility is a single-story home with 4 bedrooms, 2 bathrooms, a living room, a kitchen, a dining room, a laundry room, a front yard (not fenced), a backyard (fenced), and a garage. There is a fireplace, located in the living room, barricaded by a metal screen.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERVELEON, JESSICA
FACILITY NUMBER: 304314493
VISIT DATE: 03/13/2025
NARRATIVE
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Based on the Facility Sketch LIC999 submitted, areas off-limits to children and parents are as follows: Applicant has designated the 4 bedrooms, 1 bathroom that is inside the master bedroom, the kitchen, the laundry room, and garage as the off-limits areas. The applicant has the rooms locked and a safety door knob on the laundry room that leads to the garage ensuring this area is inaccessible to the children in care.

The applicant understands that licensing staff may have access to off-limits areas during inspection visits if necessary.

Areas Designated for Day Care Activities: The applicant has designated the living room, bathroom that is located in the hallway, the dining room, front yard, and back yard as the day care areas. The children will be napping in the living room.

Garage will not be used for day-care. The applicant stated the garage will be off-limit.

Garage is to be utilized for limited activities, day-care children are not to napped or eat in the Garage.

Areas that will be used by children were inspected for safety, comfort, cleanliness, telephone service (cell phone), ventilation, and heating. The children’s bathroom was observed to be safe and free of hazardous items. The designated childcare areas were observed to have age-appropriate toys and educational items.

Detergents, cleaning compounds, medicines, sharp objects, and hazardous items that can pose a danger to children are inaccessible in areas designated for children. The applicant stated that there are no poisons on the premises and LPA did not observe any. The applicant was advised that any poisons must be locked with a key or combination lock. The applicant stated that there are no weapons or firearms on the premises. The LPA informed the applicant that when firearms are present, they must be locked and stored separately from the ammunition per CCR 102417(g)(4)(C).



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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERVELEON, JESSICA
FACILITY NUMBER: 304314493
VISIT DATE: 03/13/2025
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The pressure gauge on the 2A-10BC fire extinguisher indicates fully charged, as indicated on the service tag observed. Smoke and carbon monoxide detectors are combine and were tested and are operable. The fire extinguisher type 2A-10BC must be serviced annually or as often as necessary. Smoke and carbon monoxide detectors should be checked, and batteries replaced as needed. The pressure gauge on the 2A-10BC fire extinguisher indicates fully charged, as the fire extinguisher is new and is located in the living room.

OUTDOOR PLAY AREA: Outdoor play activities will be conducted in the backyard and front yard. The backyard is appropriately fenced. The front yard is not fenced. LPA observed age-appropriate play equipment to be free from hazards. There are no bodies of water on the premises. LPA observed construction in the backyard and there is tarp that divides the construction area. Applicants stated they will not use the backyard area during construction. Applicants will use the front yard during construction. LPA stated to applicants that 100% supervision needs to be provide when taking the children to play in the front yard area.

The applicant was informed that if children bring food from home, the children’s names must be labeled on their lunch bags and refrigerated/stored properly.

Per the applicants, children will nap in the living room. Children will nap on mats and infants in play yards. The licensee understands that there shall be one crib or play yard for each infant who is unable to climb out of the crib or play yard.


The applicants stated that parents will provide linens and blankets for napping. The applicant stated that parents will provide diapers, lotion, wipes, and formula for the infants. Per the applicant, a changing table will be used to change diapers. The changing table is located in the dining room. LPA advised the applicants to always supervise at all times infants when changing their diapers.


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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERVELEON, JESSICA
FACILITY NUMBER: 304314493
VISIT DATE: 03/13/2025
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A records review indicates the applicant completed the required Health and Safety Training with Nutrition and Lead Poisoning components. The applicants have a current (EMSA approved) Pediatric First Aid and Pediatric CPR certification that expires on 3/8/2027 and 1/11/027. A first aid kit is available at the facility and is located in the hallway closet inside a closet.

Per the applicant, there are no dual licenses at this address. The applicant’s email address was obtained during this inspection. The applicant was advised that the email address may be public information.

In the absence of the licensee, a qualified adult must be present to supervise the children—a qualified adult is an individual who has a valid and current Pediatric First Aid and Pediatric CPR certification, TB clearance and immunization, and valid criminal record clearance that is associated with the licensed facility.

Annual fees must be paid by the due date, or a late fee shall be assessed and/or the License may be terminated.

The Child Advocacy Program was discussed with the applicant. The applicant was advised to register for the program to receive quarterly reports and other information in a timely manner. To register email ChildCareAdvocatesProgram@dss.ca.gov.

Reporting Requirements:

1. Changes should be reported to the Department as soon as they occur, such as construction, remodeling, telephone number changes, and/or moving out from your home.

2. Any unusual incidents or injuries must be reported to the Department within 24 hours via telephone and within seven (7) days in writing.

Each family childcare home must conduct fire drills and disaster drills at least once every six months. The licensee must document the date and time of each drill. This documentation must be kept at the facility for review by the Department.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 4 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERVELEON, JESSICA
FACILITY NUMBER: 304314493
VISIT DATE: 03/13/2025
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No smoking, No Johnny jumpers, No saucer chairs: any other items that fall into that category are prohibited in the facility.

Inspection Authority: All adults living and working in the home shall be made of aware of the Department’s right to inspection authority, which includes but is not limited to the right to enter the home.
when children are being cared for, interview children and adults, and review documentation.

Licensees must post each facility license number in all advertisements, publications, or announcements with the intent to attract clients.

H&S 1597.622: Commencing September 1, 2016, a person shall not be employed or volunteer at a family day care home if he or she has not been immunized against influenza, pertussis, and measles. The applicant has submitted proof of immunizations.

Health and Safety Code 1596.7995: Beginning January 1, 2018, all licensed providers, applicants, directors, and employees must complete training as specified on mandated reporter duties. Training is available at www.mandatedreporterca.com. The applicants have completed the required mandated reporter training. Recertification is required every two years.

The LPA advised the applicants on how to access forms, regulations, and quarterly updates on the Child Care Licensing website at: www.cdss.ca.gov/inforesources/community-care-licensing. LPA reviewed and issued the LIC311D “Forms/Records to Keep in Your Family Child Care Home” and provided the forms below.

Note: Children and Staff records must be kept and updated as necessary and must be available for review by the Department.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 5 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERVELEON, JESSICA
FACILITY NUMBER: 304314493
VISIT DATE: 03/13/2025
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CHILDREN FORMS/RECORDS - Children’s files must contain the following completed documents and information:
Identification and Emergency Information (LIC 700), Consent for Emergency Medical Treatment (LIC 627), Affidavit Regarding Liability Insurance (LIC 282), Parent Notification Additional Children in Care (LIC 9150), Notification of Parent’s Rights (LIC 995A), Caregiver Background Check Process (LIC 995E), California School Immunization Record (CDPH 286), Individual Infant Sleeping Plan (LIC 9227), Risk and Effects of Lead Poisoning (PUB 515), Family Child Care Consumer Awareness Information (LIC 9212), Blood Glucose Testing Consent/Verification (LIC 9222), Nebulizer Care Consent/Verification (LIC 9166), Acknowledgment of Receipt of Licensing Reports (LIC 9224).

FACILITY FORMS/RECORDS - Facility files must contain the following documents/information:
Emergency Disaster Plan (LIC 610A), Earthquake Preparedness Checklist (LIC 9148), Unusual Incident/Injury Report (LIC 624B), Child Care Facility Roster (LIC 9040), Property Owner/Landlord Notification (LIC 9149), Property Owner/Landlord Consent (LIC 9149), Entrance Checklist – Family Child Care Homes (LIC 126), Forms/Records to Keep In Your Family Child Care Home (LIC 311D), Safe Sleep Flyer-What Does A Safe Sleep Environment Look Like?, Never Ever Shake A Baby Brochure.


STAFF FORMS/RECORDS - Facility files must contain the following documents/information:
Personnel Records as specified in Title 22 Regulations 102416.1, Notice of Employee Rights (LIC 9052), one Statement Acknowledging Requirement to Report Suspected Child Abuse (LIC 9108) per provider, Copy of Pediatric Cardiopulmonary Resuscitation & Pediatric First Aid (CPR & First Aid Certification), Proof of pertussis, measles, and Tuberculosis (TB) vaccines, Proof of influenza vaccine (or documentation of exemption), Proof of Mandated Reporter Training certificate, Copy of Criminal Background Clearance Transfer Request (LIC 9182), Copy of Criminal Record
Exemption Transfer Request (LCI 9188).

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 6 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERVELEON, JESSICA
FACILITY NUMBER: 304314493
VISIT DATE: 03/13/2025
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INFORMATION TO BE POSTED IN YOU FAMILY CHILD CARE HOME – You are required by law to post the following:
Facility License (LIC 203), Waivers (if applicable), Notification of Parent’s Rights Poster (PUB 394), Earthquake Preparedness Checklist (LIC 9148), Emergency Disaster Plan (LIC 610A) California Car Seat Law (PUB 269). ). A Notice of Site Visit (LIC 9213) must be posted for 30 days after each site inspection by a Licensing Representative. Any Licensing Report documenting a Type “A” deficiency must be posted for 30 days during the hours that children are in care. Any Licensing Report or other document verifying compliance or non-compliance with the Department’s order to correct a Type “A” deficiency must be posted for 30 days during the hours that children are in care.

OTHER INFORMATION AND FORMS PROVIDED: (Posters were emailed to the Licensee)
Capacity Handouts for a Small Family Child Care Home and Large Family Child Care Home were provided.

The following was discussed with the applicant:

Criminal Record Clearance

Applicants were 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, 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.


Landlord Consent

Because the applicants’ rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 7 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERVELEON, JESSICA
FACILITY NUMBER: 304314493
VISIT DATE: 03/13/2025
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Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, an updated Plan of Operation that includes 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) or (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 Incidental Medical Services (IMS) - Family Child Care Homes

Review of records to be maintained:

LPA reviewed with applicants 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 applicant.

Safe Sleep

LPA discussed the safe sleep regulations with the 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. LPAs also informed the 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.

Megan’s Law

On this date, 3/13/2025, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

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SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 8 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY CC RO, 750 THE CITY DRIVE, SUITE 250
ORANGE, CA 92868
FACILITY NAME: SERVELEON, JESSICA
FACILITY NUMBER: 304314493
VISIT DATE: 03/13/2025
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MyChildCarePlan.org

Applicants was informed of the MyChildCarePlan.org site, 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.

Notice of Site Visit


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

Exit Interview
Exit interview conducted and report was reviewed with the Jessica Serveleon and Stephanie Toga Dominguez. Subscribe to CCLD important information - Child Care Centers and Family Child Care Homes:

Subscribe to CCLD important information
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 platforms.
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.

Once licensed, the applicant is required to adhere to the terms and limitations stated on the license. A copy of this report and all other Licensing reports must be made available to the public for 3 years.



The Small Family Child Care Home was in compliance with Title 22 Regulations at the time of inspection. In the event additional requirements are needed, the applicant will be notified.

In the event additional requirements are needed, the applicant will be notified. A license will be issued once all requirements are met and final approval from management.

Appeal rights were provided. Exit interview conducted and report was reviewed with Jessica Serveleon and Stephanie Toga Dominguez Page 9 of 9
SUPERVISORS NAME: Thuy Ho
LICENSING EVALUATOR NAME: Aiddee Nunez
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 9 of 9