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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 376629111
Report Date: 08/13/2021
Date Signed: 08/17/2021 08:59:25 AM

Document Has Been Signed on 08/17/2021 08:59 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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME:THOMAS, JAZMINE FAMILY CHILD CAREFACILITY NUMBER:
376629111
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
08/13/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Jazmine ThomasTIME COMPLETED:
10:00 AM
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On 08/13/21 at 9:45am, Licensing Program Analyst (LPA) Adrian Castellon conducted an announced Pre-Licensing inspection with applicant/licensee Jazmine Thomas. Purpose of the visit is to ensure that the home is in compliance with standards established in CCR, Title 22, Division 12, Chapter 3. Applicant Thomas recently submitted a change of location application. This 4 bedroom, 3 bath home was toured and inspected to ensure an environment safe for the care and supervision of children. Applicant is purchasing the home and has provided proof. Applicant will use the following areas for child care: living room, dining area, daycare room and hallway bathroom. Off limits areas include: second floor (staircase is properly barricaded via babygate) and the laundry room which is properly secured. Applicant will utilize the front, back and side yards for outdoor activities. There are no bodies of water observed during time of visit. Applicant states that there are no firearms in the home. The fire extinguisher, carbon monoxide detector and smoke detector meet requirements and are operational. All poisons, cleaners and hazardous items in the home are inaccessible to children through latches, locks, and/or placed up on high surfaces. Children’s toys and play equipment are available. Applicant states there are no firearms or other weapons in the home. Applicant has completed the 8 hours of preventative health. Lead poising training has been completed. Pediatric CPR and First Aid certifications expire on 04/23. Required documents are posted. All adults residing in the home and have been cleared for criminal record and child abuse index clearances. Applicant was advised that any new/additional adults must be cleared prior to working or residing in home. Any minor upon his/her 18th birthday must be fingerprinted within 30 days. Applicant is exempt from Mandated Reporter AB1207 training has been completed. LPA Castellon reviewed an child's folder during the inspection.
SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Adrian Castellon
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2021
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, 7575 METROPOLITAN DR., STE 110
SAN DIEGO, CA 92108
FACILITY NAME: THOMAS, JAZMINE FAMILY CHILD CARE
FACILITY NUMBER: 376629111
VISIT DATE: 08/13/2021
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Incidental Medical Services (IMS) policy was discussed. For IMS information see Evaluator Manual - Regulation Interpretations and Procedures for Family Child Care Homes Section 102417. 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: http://www.ada.gov/childqanda.htm

Applicant was advised to regularly visit the Community Care Licensing WEB SITE: http://www.ccld.ca.gov/ for quarterly updates and updated regulation information. Duty Line was provided: (619) 767-2248. LPA's discussed California Megan's Law and LPA provided: www.meganslaw.ca.gov

SAFE SLEEP PLAN and documentation was discussed. The provider physically checks on sleeping infants every 15 minutes. An Individual Infant Sleeping Plan [LIC 9227 (3/20)] is maintained for each infant up to 12 months of age and shall be available to the Department for review. The provider places infants up to 12 months of age on their backs for sleeping.

Applicant states that she will comply with all regulations and laws governing family child care homes and that she is financially secure to operate a family child care home for children. LPA reviewed this report with Applicant prior to obtaining his signature.

Prior to a license being issued, the following must be corrected: back yard must be cleared of gardening tools and shed located iin the backyard must be secured. Also, LIC508, picture ID and transfer request must be submitted so that prints may be transferred. Applicant will submit proof of corrections by 08/20/21

SUPERVISORS NAME: Cynthia Gray
LICENSING EVALUATOR NAME: Adrian Castellon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC809 (FAS) - (06/04)
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