Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 073406355
Report Date: 02/17/2017
Date Signed: 02/17/2017 12:42:58 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME:JACKSON, NORA & MICHAELFACILITY NUMBER:
073406355
ADMINISTRATOR:JACKSON, NORA & MICHAELFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(925) 709-1241
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY:14CENSUS: 7DATE:
02/17/2017
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:NORA JACKSONTIME COMPLETED:
01:00 PM
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(1)LPA Tasha Alexander met with licensee Nora Jackson for an unannounced ANNUAL/RANDOM visit. Present for the visit were licensee, her new assistant/grand daughter Yazmeen Sepulveda and 7 children in care, consisting of 1 infant and 6 preschoolers. LPA toured the facility and backyard for a health and safety inspection. The children's files contained emergency information and immunization blue cards. The home is equipped with a 2A10BC fire extinguisher, working smoke detector and working carbon monoxide detector. There is a working telephone in the home. Per licensee there are no fire arms on the premises. There are no pools, hot tubs, or other bodies of water at the home. All poisons, cleaning solutions and medications are inaccessible to children. Licensee has current CPR and 1st Aid training which expires 9/21/18 respectively. The off limits areas are master bedroom/bath, 2nd bedroom and garage. Licensee was also informed of the licensing web address (www.ccld.ca.gov) for downloading child care forms and (www.myccl.com) to register to receive child care updates.
A review of staff records on 2/17/17 indicates that all facility staff or other individual who required caregiver background checks have received criminal record and child abuse index clearances or exemptions.

Effective September 1, 2016, a person may not work or volunteer at a child care center or family child care home unless he or she has been immunized against pertussis, measles and influenza or has an exemption.

As a result of this visit, there are no deficiencies cited today. This report must be available for public review for 3 years. An exit interview was conducted. A notice of site visit was posted.

SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2017
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, 1515 CLAY STREET, SUITE 1102
OAKLAND, CA 94612
FACILITY NAME: JACKSON, NORA & MICHAEL
FACILITY NUMBER: 073406355
VISIT DATE: 02/17/2017
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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

SUPERVISOR'S NAME: Diane PerezTELEPHONE: (510) 622-2593
LICENSING EVALUATOR NAME: Tasha Hackett-AlexanderTELEPHONE: (510) 622-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2017
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2017
LIC809 (FAS) - (06/04)
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