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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 414002790
Report Date: 10/12/2022
Date Signed: 10/12/2022 01:39:55 PM

Document Has Been Signed on 10/12/2022 01:39 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:JENSEN, THERESA MARIEFACILITY NUMBER:
414002790
ADMINISTRATOR:JENSEN, THERESA MARIEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(650) 296-9625
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 14TOTAL ENROLLED CHILDREN: 7CENSUS: 4DATE:
10/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Theresa JensenTIME COMPLETED:
01:56 PM
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On October 12, 2022 at 12:00 PM, Licensing Program Analyst (LPA) April Cowan conducted an unannounced Annual Inspection and met with Licensee. LPA disclosed the purpose of the inspection and was granted entry into the facility by the Licensee. Present in the facility is Licensee and helper, Veronica Escareno, caring for 4 preschool age children. Licensee lives in a 2 bedroom with spouse and adult daughter. Facility was inspected and Day-care areas are: Living Room, Dining Room, Bathroom, and Back Yard. The rest of the home is off-limits. Day and hours of operation : Monday – Thursday, 9:00 AM to 4:00 PM.

At 12:03 PM, LPA observed the following: Day-care area is clean, orderly, and equipped with age appropriate toys and equipment for the children. Home has sufficient lighting and ventilation. Home has a working telephone, a working smoke and carbon monoxide detector, and a fully charged fire extinguisher. There are no poisons, detergents, or cleaning products accessible to day-care children. Licensee states there are no guns or weapons of any kind in the home. Licensee’s CPR expires in 6/26/23. Licensee conducted last emergency drill on 7/6/22 and is properly logged. Discipline policy is mainly redirection. All required postings are properly posted.
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE: DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/12/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JENSEN, THERESA MARIE
FACILITY NUMBER: 414002790
VISIT DATE: 10/12/2022
NARRATIVE
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During inspection,
Precautions for the COVID-19 were discussed. Emergency Evacuations were discussed. Facility files were discussed.

At 12:32 PM, LPA reviewed facility files. Children's files are complete with all required Licensing documents. Staff has fingerprint clearance and Acknowledgment to Report Child Abuse on file.

*Licensee was reminded about having all Staff and Volunteers provide proof of immunization against influenza, pertussis, and measles or qualifies for an exemption.
*Licensee was reminded about the Provider Information Notices (PINs) on CCLD website.
*Licensee was reminded about Mandated Reporter Training available on CCLD website (www.ccld.ca.gov or www.mandatedreporterca.com)
*Licensee was given information regarding ‘Safe Sleep’ practices.

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
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SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JENSEN, THERESA MARIE
FACILITY NUMBER: 414002790
VISIT DATE: 10/12/2022
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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.

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-and-resources/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.

Exit interview conducted and report was reviewed with the licensee Theresa Jensen .


>No deficiencies were issued today under Title 22 Division 12 of the Ca. Code of Regulations.


>This report and rights to comment and appeal were discussed with Licensee. This report must be available in the facility for public review. A notice of site visit was given and must remain posted for 30 days.
Licensee was advised any additional questions to call Office, M-F, 8am-5pm, 650-266-8800 or 1-844-538-8766. Website: www.cdss.ca.gov
SUPERVISORS NAME: Garfield Leung
LICENSING EVALUATOR NAME: April Cowan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022
LIC809 (FAS) - (06/04)
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