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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500459
Report Date: 08/04/2021
Date Signed: 08/12/2021 09:05:28 AM

Document Has Been Signed on 08/12/2021 09:05 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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:WILLIAMS, JER'NEEFACILITY NUMBER:
394500459
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 1DATE:
08/04/2021
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Jer'Nee WilliamsTIME COMPLETED:
04:15 PM
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On 4th August 2021 at 2:00pm Licensing Program Analyst (LPA) Aruna Sridharan met with licensee Jer'Nee Williams for an announced change of location per licensee's request. Licensee moved from previous licensed(393621519) address: 2987 Appling Circle, Stockton CA 95209 to current home at 6298 Crestview Circle, Stockton, CA 95219. The hours of operation are 24 hours. All adults are fingerprint cleared.
LPA toured the home inside and out. The licensee owns the home which is a two storey home with four bedrooms and three bathrooms. OFF LIMIT areas include: entire upstairs, garage, laundry room and downstairs master bedroom/bath. Licensee acknowledges that children may never enter these off-limit areas.
The entire outside area was toured and no bodies of water were found. The front yard is unfenced and the backyard area is fenced. The licensee understands that 100% supervision is needed when children are in an unfenced area. Licensee understands that prior to making altercations or additions to the home or grounds the licensee shall notify Licensing Agency per regulation 102416.3
Home has working carbon monoxide and smoke detectors that meet regulations. The 2A-10-B-C fire extinguisher is in the kitchen wall mounted and first aid kit in hall closet. The stairs are barricaded, fireplace is screened. There are no firearms as stated by licensee. Hazardous cleaning compounds are stored in the locked cabinet under the sink. Sharp utensils like knives are stored in the corner upper cabinet. The medications are stored in upper cabinet in the pantry in the dinning area. The home contains appropriate toys for the children.
The Licensee has proof of enrollment for Lead Poisoning Prevention module on August 7th 2021. Licensee has CPR and First Aid (exp:07/2023) and Mandated Reporter (exp: 08/2023).
Licensee was advised to follow COVID guidelines and precautions to provide care for children at this time.
LPA has provided the licensee with the web site www.ccld.ca.gov and reminded of their responsibility to stay current in the requirements of the Department. LPA reviewed the fire drill requirements. LPA reviewed postings. Licensee currently does have liability insurance.
LPA will recommend approval for a Provisional license for change of location as of today.
Notice of Site Visit was posted.
SUPERVISORS NAME: Sharon Ogbodo
LICENSING EVALUATOR NAME: Aruna Sridharan
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
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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