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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 393600292
Report Date: 07/19/2024
Date Signed: 07/23/2024 03:06:43 PM

Document Has Been Signed on 07/23/2024 03:06 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 S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ADDI, JACQUELINEFACILITY NUMBER:
393600292
ADMINISTRATOR/
DIRECTOR:		ADDI, JACQUELINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(209) 403-1904
CITY:STOCKTONSTATE: CAZIP CODE:
95209
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 6DATE:
07/19/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Jacqueline AddiTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 07/19/24, Licensing Program Analyst (LPA) Elvira Sierra met with Licensee, Jacqueline Addi for the purpose of an unannounced annual inspection. Licensee is requesting to change her hours of operation. New facility hours of operation are M-F 07:00 am to 05:30pm. Licensee stated that no new residents moved into the home since licensure. Entrance Checklist for Family Child Care Homes was provided. There were 6 children present during inspection. Two children were Licensee's grandchildren.

A health and safety inspection was conducted in all areas accessible to children.Off limits areas area:


Garage and all bedrooms. Facility maintains a working phone, 2A10BC fire extinguisher, and functioning smoke/carbon monoxide detector. Cleaning and hazardous items are stored inaccessible to children. Age-appropriate toys and reading material were observed. The fireplace in the home is appropriately barricaded to prevent access to children. There is a swimming pool in the facility that is fenced according to Title 22. At this time the swimming pool is under repair and has no water. Facility representative was reminded that 100 percent supervision is required on unfenced areas and to notify LPA of any changes on facility hours of operation, changes to the off limits areas or vice versa and any new construction to the home.
Current in person EMSA CPR and First Aid certification for licensee expires 01/28/2025. Mandated Reporter Training for Licensee expires on 10/17/24. LPA observed a current roster and fire drills are conducted at least once every six months and are properly log.

LPA verified the annual fees are current. LPA explained to Licensee that absences shall not exceed 20 percent of the hours that the facility is providing care per day. Licensee must notify the department anytime facility is closing for vacation or any other leave that the Licensee requires to be absence more than 20 percent per day.

Report continues on subsequent page 809C--

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ADDI, JACQUELINE
FACILITY NUMBER: 393600292
VISIT DATE: 07/19/2024
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Licensee was reminded that all adults 18 and over living or working in the home, 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.

Licensee acknowledge that a Plan for Providing IMS must be submitted to the Department if provided. 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.

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.

To improve the quality and value of the new inspection process, a survey will 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 tools, please send them by email 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/process

The licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to childcare providers and Resource and Referral Agencies (R&Rs) throughout California.

Report continues subsequent 809C...

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
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
SACRAMENTO S. CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ADDI, JACQUELINE
FACILITY NUMBER: 393600292
VISIT DATE: 07/19/2024
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During the exit interview, Licensee, Jacqueline Addi confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

A notice of site visit was posted and must remain posted for 30 days. Exit interview conducted and report was reviewed with Licensee, Jacqueline Addi.

SUPERVISORS NAME: Bettina Engelman
LICENSING EVALUATOR NAME: Elvira Sierra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
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