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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 394500576
Report Date: 06/29/2022
Date Signed: 06/29/2022 12:14:45 PM

Document Has Been Signed on 06/29/2022 12:14 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME:GIBSON, JENNIFERFACILITY NUMBER:
394500576
ADMINISTRATOR:FACILITY TYPE:
810
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY: 8TOTAL ENROLLED CHILDREN: 8CENSUS: 0DATE:
06/29/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Jennifer GibsonTIME COMPLETED:
12:30 PM
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On 06/29/2022, Licensing Program Analyst Katy Maestas (LPA) met with Applicant Jennifer Gibson (A1) for the purpose of a prelicensing inspection. LPA disclosed the purpose of the inspection and was granted entrance into the Family Childcare Home (FCCH). Also present in the FCCH was A1's husband, adult brother and minor child. All individuals subject to criminal background review have obtained a criminal record clearance verified by LPA accessing Guardian. Licensee’s tentative hours of care are Monday through Friday, from 6:00 AM until 6:00 PM.

A health and safety inspection was conducted inside and outside of the home. A1 accompanied LPA for the entirety of the tour. The FCCH is a one story house with a kitchen, living room, bathroom, 3 bedrooms, master bedroom and bathroom, and access to the garage. LPA verified toxic and hazardous items were inaccessible to children in care. LPA did not observe any stairs nor fireplaces. The OFF-limits areas in the home are the garage, the master bedroom and bathroom, and the front two bedrooms. OFF-limits areas will remain inaccessible to children. The outdoor play area was toured which includes the backyard, patio, side yards and front yard. LPA verified that the entirety of the FCCH is fenced-in and walked the perimeter to ensure the safety of the fence and gate. LPA did not observe any pool, spa or water feature.

A functioning dual smoke and carbon monoxide detector was observed in the hallway off the living room. LPA observed cleaners stored in the kitchen and bathroom cabinets that have safety locks on the doors and drawers. A 2A10BC fire extinguisher was observed in the kitchen, and a first aid kit was observed also observed in the kitchen. A1 stated there are no weapons in the home.



LPA discussed Mandated Reporter Training with A1. Health and Safety Code 1596.8662 requires all licensed providers, applicants, directors and employees to complete training as specified on their mandated reporter duties and to renew their training every two years. Volunteers are encouraged but not required to take the training.

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SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: GIBSON, JENNIFER
FACILITY NUMBER: 394500576
VISIT DATE: 06/29/2022
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This training requirement may be met by using the Department’s Office of Child Abuse Prevention (OCAP) online training modules. The OCAP modules are free of cost and available at: http://www.mandatedreporterca.com/. The training is currently provided in English. Applicant has a current Mandated Reporter Training Certificate which will expire on 06/08/2024. Current Pediatric CPR and First Aid training was verified and expires on 04/23/2024.

LPA discussed the Safe Sleep Regulations with A1 and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed A1 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 with A1. 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: 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 platform. 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.

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SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
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, 2525 NATOMAS PARK DR. STE 250
SACRAMENTO, CA 95833
FACILITY NAME: GIBSON, JENNIFER
FACILITY NUMBER: 394500576
VISIT DATE: 06/29/2022
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A1 was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, 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.

A1 understands that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours. A1 understands that if an unusual incident occurs; licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance. A1 understands that if any structural changes are made to the home; licensing must be notified PRIOR to construction.



A1 understands that if she wants to make any OFF-limit area an ON-limit area, she must notify licensing and LPA must do an inspection BEFORE children are allowed in the area. A1 understands that children’s records are to be maintained according to Title 22 regulations and be accessible to licensing for up to 3 years.

LPA reviewed with Licensee the LIC 311D, Forms/Records To Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. The Entrance Checklist was provided to the applicant.

As of today, 06/29/2022, Applicant will be approved for a Small Family Child Care Home license for a capacity of 8 children with no more than 3 infants, or 4 infants only, or up to 8 children with no more than 2 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2. A1 has not provided LIC 9149 to the Regional Office and therefore, understands that she cannot provide care for more than 6 children.

An exit interview was conducted, and the report was reviewed with A1. Licensee Appeal Rights were provided. A notice of site visit was posted by LPA and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.

SUPERVISORS NAME: Jeanne Smith
LICENSING EVALUATOR NAME: Nola Maestas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2022
LIC809 (FAS) - (06/04)
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