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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 340319878
Report Date: 01/05/2024
Date Signed: 01/05/2024 04:17:33 PM

Document Has Been Signed on 01/05/2024 04:17 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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:B.J. JORDAN CHILD CARE - JEFFERSONFACILITY NUMBER:
340319878
ADMINISTRATOR:HECTOR RAMOSFACILITY TYPE:
850
ADDRESS:2001 PEBBLEWOOD DRIVETELEPHONE:
(916) 920-8188
CITY:SACRAMENTOSTATE: CAZIP CODE:
95833
CAPACITY: 25TOTAL ENROLLED CHILDREN: 25CENSUS: 5DATE:
01/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Tarra KleiserTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Erwina Pascual-Golamco and Jennifer Velasco, met with Facility Representative, Tarra Kleiser (FR), for a case management visit regarding an incident that occurred on 12/21/23. Purpose of the visit was explained.

The facility representative self reported to the department on 12/22/23 and submitted a written Unusual Incident Report LIC624, that on 12/21/23, a child was left in play yard without supervision for approximately 1 minute and 52 seconds, when the children transitioned from outdoor play. Approximate time was from video footage that the FR observed. During today's inspection, LPA observed the classroom, play yard, and interviewed staff. FR and staff stated that face to name roll call was done, but somehow child stopped walking and staff got in front of the child and did not make it to the ramp to the classroom. FR stated that staff were spoken to individually and Active Supervision strategies were retrained from December 27-29, 2023.

Based on observation, interview, and record reviews, Title 22 Deficiencies have been issued on the attached LIC 809-D page. Facility Representative was informed that the Type A deficiency cited today is an immediate civil penalty, for absence of supervision, and is being assessed in the amount of $500. Facility Representative shall also provide a copy of this licensing report to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. Exit interview was conducted with Facility Representative, appeal rights were provided, and A notice of site visit was given to Facility Representative, who will post it where visible to parents/guardians for 30 days. A signed Acknowledgement of Receipt of the Licensing Report (LIC 9224) must be placed in the child's file for verification.
SUPERVISORS NAME: Natalie Dunaway
LICENSING EVALUATOR NAME: Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
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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Document Has Been Signed on 01/05/2024 04:17 PM - It Cannot Be Edited


Created By: Erwina Pascual-Golamco On 01/05/2024 at 09:51 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: B.J. JORDAN CHILD CARE - JEFFERSON
FACILITY NUMBER: 340319878

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2024
Section Cited
CCR
101229(a)(1)

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101229 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the children's needs. (1) No child(ren) shall be left without the supervision of a teacher at any time...shall include visual observation.
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Facility Representative (FR) stated that staff were spoken to individually and Active Supervision strategies were retrained from December 27-29, 2023. FR will email copies of training documentation and staff statements to LPA by 4PM POC due date.
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This requirement is not met as evidenced by: based on observation, interview, and record reviews, FR did not comply with the section cited above as a child was left unsupervised in the play yard, for approximately 1 minute and 53 seconds, which poses an immediate health, safety, or personal rights risk to persons 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:Natalie Dunaway
LICENSING EVALUATOR NAME:Erwina Pascual-Golamco
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


LIC809 (FAS) - (06/04)
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