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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 434405858
Report Date: 10/16/2024
Date Signed: 10/18/2024 09:11:19 AM

Document Has Been Signed on 10/18/2024 09:11 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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:HACKETT, JOSEPHINEFACILITY NUMBER:
434405858
ADMINISTRATOR/
DIRECTOR:		HACKETT, JOSEPHINEFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(408) 421-9127
CITY:SANTA CLARASTATE: CAZIP CODE:
95054
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 8DATE:
10/16/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Josephine HackettTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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LPA(Licensing Program Analyst) Anna Morales conducted an unannounced Annual/Required Inspection. LPA met with Licensee, Josephine Hackett and her husband (staff). Present in the home were eight day care preschool aged children. Children were playing under the supervision of the Licensee and staff. Days and hours of operation are Monday - Friday from 7:30 AM -6:00 PM. Adults over the age of 18 and residing in the home are the Licensee, her spouse and her son. All adults have Criminal Background Check Clearances. LPA reviewed a Children's Roster.
Last disaster drill was conducted 10/16/2024.

Licensee Josephine Hackett was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, 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 for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

LPA toured the indoor and outdoor areas of the home during today's inspection. The Licensee has a working telephone in the home. LPA observed sufficient materials, toys, and play equipment for the day care children. The home is clean, orderly, and safe. LPA did not observe any wall heaters inside the home. The fire place in the living room is barricaded. Off limit areas in the home: 3 bedrooms and front living room. There are no stairs inside the home. Off limit areas outside the home: detached garage & right side section of the backyard.


SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HACKETT, JOSEPHINE
FACILITY NUMBER: 434405858
VISIT DATE: 10/16/2024
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LPA observed a fully charged 3A40BC fire extinguisher, working smoke/carbon monoxide detectors, fenced backyard, and no bodies of water. The Licensee states that she does not have any pets or weapons in the home. All detergents, cleaning compounds, medications, and other similar items are inaccessible to children.

Incidental Medical Services (IMS) policy was discussed. 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: https://www.ada.gov/resources/child-care-centers/.

Staff stated has a first aid kit in the day care. Staff stated that nobody smokes, and she understands that smoking is prohibited in the day care.

LPA reviewed a random selection of children's file and observed that parent's rights forms, immunization records forms, consents for emergency medical treatment forms, and Identification forms are in each file.

Licensee and Staff files were reviewed for the following records: Employee Rights (LIC9052), Statement Acknowledging Requirement to report Child Abuse (LIC9108), and Immunization Record showing immunity to measles (MMR), pertussis (Tdap), and influenza (or statement declining influenza).

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-andresources/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.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
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
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME: HACKETT, JOSEPHINE
FACILITY NUMBER: 434405858
VISIT DATE: 10/16/2024
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To improve the quality and value of the new inspection process, a survey may 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 CARE tools, please send email inquiries 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/inspection-process.


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

During the exit interview, the Licensee Josephine Hackett, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

LPA issued one Technical Violation for forms (LIC627 and LIC995)not being found in two of the Children's files.

A notice of site visit was given and must remain posted for 30 days.

Exit interview conducted and report was reviewed with the licensee Josephine Hackett.

SUPERVISORS NAME: Gladys Kuizon
LICENSING EVALUATOR NAME: Anna Morales
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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