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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343618891
Report Date: 04/16/2024
Date Signed: 04/16/2024 12:52:58 PM

Document Has Been Signed on 04/16/2024 12:52 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:CALDERON, JACQUELINEFACILITY NUMBER:
343618891
ADMINISTRATOR/
DIRECTOR:		CALDERON, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 534-5152
CITY:SACRAMENTOSTATE: CAZIP CODE:
95834
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
04/16/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Jacqueline CalderonTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On April 16th, 2024 Licensing Program Analyst (LPA) Mandie Goodwin met with Licensee Jacqueline Calderon, for the purpose of an unannounced required inspection. Also in the home was Licensee’s daughter acting as an assistant. All individuals subject to criminal background review have obtained a criminal record clearance. LPA observed there were eight daycare children including 5 infants during inspection. Licensee stated that a part time child who doesn’t normally attend at the same time as the other infants was present today. Facility days and hours of operation are Monday-Friday 8:00am-4:30pm.

Licensee guided LPA on a tour of the facility and a health and safety inspection was conducted in all areas accessible to children. The off-limits areas include entire upstairs, laundry room, daughters room, and gated side yard. Licensee acknowledges that children may never enter the off limit areas. LPA observed the required postings, a fully charged fire extinguisher, and smoke and carbon monoxide detectors. Per Licensee, there are no weapons in the home. No bodies of water were observed today. Toxic and hazardous items are inaccessible to children. Outdoor play space is fenced and in good repair.

LPA observed that six children were napping in pack and plays. The pack and plays each had a black sheet covering 4 sides of the pack and play and there was bedding and stuffed animals inside the pack and plays. Licensee stated that the parents asked her to let the children have blankets and she removed all the bedding during time of visit.

LPA reviewed eight children’s files and verified birth dates using immunization records. There were five infants under the age of 2 in attendance, putting facility over capacity. LPA discussed the requirements for Notification of Parents Rights to be added to each file. A current children’s roster was observed. Licensee has record of conducting fire drills at least every six months. Per record, last drill was conducted on 4/1/2024. LPA provided and reviewed the Family Child Care Home Entrance Checklist. LPA discussed the requirement of renewing CPR and mandated reporter training every 2 years. (Report continues LIC809-C)
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE: DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2024
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 04/16/2024 12:52 PM - It Cannot Be Edited


Created By: Mandie Goodwin On 04/16/2024 at 12:01 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CALDERON, JACQUELINE
FACILITY NUMBER: 343618891

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
102425(b)
Infant Safe Sleep
(b) Cribs or play yards shall be free from all loose articles and objects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that 6 pack and plays contained bedding and stuffed animals, and were covered on all sides with a sheet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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Licensee removed all bedding and the crib coverings. LPA discussed safe sleep regulations. Cleared during time of visit.
Type A
Section Cited
CCR
102416.5(d)(1)
Staffing Ratio and Capacity
(d) For a Large Family Child Care Home, the maximum number of children for whom care may be provided at any one time when there is an assistant provider in the home, including children under age 10 who reside at the licensee's home and the assistant provider's children under age 10, shall be either: (1) Twelve children, no more than four of whom may be infants; or

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 by having 5 infants present which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2024
Plan of Correction
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LPA will return to facility to observe proper ratios.
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:Seychelle De Luca
LICENSING EVALUATOR NAME:Mandie Goodwin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024


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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CALDERON, JACQUELINE
FACILITY NUMBER: 343618891
VISIT DATE: 04/16/2024
NARRATIVE
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Licensee’s CPR is current and expires April 2025. Mandated reporter training expires April 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 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 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.

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 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. Continued on 809-C
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
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
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: CALDERON, JACQUELINE
FACILITY NUMBER: 343618891
VISIT DATE: 04/16/2024
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During the exit interview, the Licensee, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA Goodwin informed Licensee that this report dated 4/16/24 documents two Type A citations which shall be posted for 30 consecutive days as there is immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Mandie Goodwin informed the Director to provide a copy of this licensing report dated 4/16/24 that documents any Type A citation(s) 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. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification. Exit interview with Licensee Jaqueline Calderon was conducted and appeal rights were provided.

See LIC 9099-D for deficiencies.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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